Biopsychosocial Assessment

Step 1 of 8

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Collection of information for Case Management(Required)

I consent to the collection of my information for the purpose of case management

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Email:(Required)

Gender:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Living Situation?(Required)

Rent or own your home?(Required)

Length of Residing?

Children (name, age, and whether they reside with you):

Others in Residence:

Reason for Contacting Us?(Required)

General History

Place of Birth:(Required)

Birth Order?(Required)

Youngest, Middle, Oldest, Only....

Who Raised You?(Required)

Description of Home Life as a Child:(Required)

How is your current relationship with your family?(Required)

Any Developmental Milestones that were a problem?

(Talking, reading, spelling, sensory integration....)

Do you have any disabilities or need assistive devices?

Medical History

List your Current Medications (including times and doses):(Required)

Allergies (Medication, Latex, Seasonal)?

List any Current Medical Problems:

Do you have any chronic medical problems that continue to interfere with your life?

Do any of your family members have a history of chronic medical problems (e.g. diabetes, cancer...):

Have you ever been hospitalized?(Required)

Education & Occupation

What is your highest grade completed in school and level of education?(Required)

Do you have a Highschool Diploma or GED?(Required)

Do you have any technical training or certificates?

Current Employment Status?(Required)

List the Last 3 Jobs you had. (Include Location, Job Title, Date Started, Date Left, and Reason for Leaving):(Required)

Estimated Current Annual Income:(Required)

Insurance Type

Insurance Provider

Insurance Number

Relationship History & Social Support

Sexual Orientation:(Required)

Gender Expression:(Required)

What is your current relationship status (include name of partner):(Required)

Are you satisfied with your current relationship?

Whom do you spent most of your time with and how?(Required)

Have you ever engaged in unprotected sex?(Required)

Have you shared needles?(Required)

Have you experienced a history of domestic violence (victim, witness, perpetrator):(Required)

Have you experienced any of the following (list incidences & perpetrator):(Required)

Emotional Abuse:

Physical Abuse:

Sexual Abuse:

Do you have a higher power?(Required)

Do you attend any formal or informal spiritual practices (Church, Denomonation):

Do you meditate or pray?(Required)

List any leisure activities:(Required)

Mental Health

Select all Substances you have used:

Alcohol

Amphetamines

Bath Salts

Benzodiazepin

Barbituates

Cannabis

Cocaine/Crack

Hallucinogens

Heroin

Inhalants

Methadone

Nicotine

Opiates

Spices/K2

Other

What is your drug of choice?

When was your last drug use and what was used?

How often are you using?

Are you currently in treatment for addiction?

Have you experienced any consequences related to drug use?

Loss of Control

Withdrawal

Tolerance noted

Overdose

Hallucinations

Medical Problems/Injuries

Legal Problems

Blackouts

Suicidal Thoughts

Strained Relationships

Job Problems

Hangover

List prior treatment episodes of substance abuse:

Do you have any mental health concerns or are you currently being treated for one? If Yes, what are your concerns or diagnoses and where are you receiving treatment?

Military History

Have you ever served in the Armed Forces?

Branch:

Highest Rank:

Discharge Status:

Have you seen combat?

Legal History

Arrest History:

Any substance-use related arrests/charges:

How many months have you been incarcerated in your lifetime?

Do you have any pending charges?

Current Probation/Parole Status:

Level III

Level II

Level I

Parole

None current

Name of Probation Officer?

Consent(Required)

I agree that all the information I have provided is correct.

Signature

Phone

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