Biopsychosocial Assessment Form

Helps mental health professionals gather information on a patient's mood, habits, family history, and substance use before starting treatment.

Use this template

Client Name

Nombre

Apellido

Date of Birth

Age

Email Address

Contact Number

Please describe your problem.

How long have you been facing this problem?

Less than a month 1-6 months 6-12 months More than a year

How does this problem affect your daily life?

What do you expect from your therapy sessions?

Please select the symptoms you have experienced in the last 30 days

Have you ever contemplated suicide?

Yes No

Have you ever had a trauma?

Yes No

Are you pregnant now?

Yes No Not applicable

Are you at risk for HIV/AIDS?

Yes No Unsure

Do you smoke any forms of tobacco?

Yes No

Please provide more details.

Are you having any problems with alcohol?

Yes No

Please provide more details.

Are you having any problems with pills or illegal drugs?

Yes No

Please provide more details.

Who is in your family?

How are the relationships in your family?

Excellent Good Fair Poor

Are there any of the following problems in your family?

What is your marital status now?

What is your highest level of education?

High School Some College Bachelor's Degree Graduate Degree

Have you ever been arrested?

Yes No

Please provide more details.

What is your current employment status?

Employed Unemployed Student Retired

Past and current medical/surgical problems.

Please list any allergies or medications.

Anything else you would like me to know about you.

Biopsychosocial Assessment Form

Related templates