College of social sciences

1. College of Social Sciences
Master of Science
in Counseling
Biopsychosocial Assessment
NAME(S):
DATE OF BIRTH:
PRIMARY LANGUAGE:
REFERRED BY:
INTAKE DATE:
EVALUATED BY:
DESCRIPTION OF CLIENT(S):
Write what you observe about the client—age, sex, ethnicity,
appearance, behaviors, and impressions.
PRESENTING PROBLEM:
Describe the problem as the client has presented it, including
perspective, function impairment, and symptoms.

2. HISTORY OF PROBLEM:
Describe the course of the problem and specific onset and
symptoms.
MENTAL STATUS:
Activity:
Mood and Affect:
Thought Process, Content, and Perception:
Cognition, Insight, and Judgment:
Suicidal and Homicidal Assessment
If a more thorough suicide/homicide evaluation is conducted, it
may be documented in a separate section.
SOCIAL HISTORY:
Describe the client's present living situation:

3. Family:
School:
Health:
Occupational/Work:
Spiritual/Religious:
Legal:
Social History (include history of abuse/trauma):
HEALTH & WELLNESS HISTORY:
Substance use (including alcohol, drugs, tobacco and caffeine
intake):
Sleep habits:
Exercise habits:
Eating habits and appetite:
PREVIOUS THERAPY / PSYCHIATRIC SERVICES:

4. Name of Provider Clinic Year Diagnosis / Problem
_____________________________________________________
________________________________
_____________________________________________________
________________________________
_____________________________________________________
________________________________
Have you ever seen a Psychiatrist
Name of MD: _______________________________________
Clinic: _____________________________
Was any of your previous therapy related to substance abuse?
Have you ever had serious thoughts of suicide or homicide?
Explain: ____________________________
_____________________________________________________
________________________________
Do you presently feel suicidal or homicidal?
Explain: __________________________________
FAMILY RELATIONSHIP HISTORY:
Describe the client's current and historical family status and
relationships, including during childhood/adolescence.
STRENGTHS:
Describe assets that will facilitate progress and change, such as

5. motivation, intelligence, self-discipline, and willingness to
utilize resources.
CHALLENGES
Describe aspects’ of the client’s life circumstance that may
impede progress/change, such as homelessness, major
psychiatric disorder, financial hardship, etc.
DIAGNOSIS:
Using the information gathered thus far, make a diagnosis using
DSM 5.
DISCUSSION/CLINICAL FORMULATION:
Provide your rationale for the provided diagnosis. Describe the
appropriate theory to consider using with this client. Note the
basics of this theory and how it might apply to this client.

6. _________________________________________________
__________________
Student/Counselor in Training
Date
_________________________________________________
__________________
Supervisor Date
CCHM/558 v2
Title
CCMH/558 v2
Page 2 of 2
Case Conceptualization ScenarioJessica
Jessica is a 25-year-old single female having difficulty with
high anxiety, fears of getting close to people, feeling the need
to be constantly perfect, and she states that she is unable to
simply relax. Her sleep patterns are erratic, and she often wakes
up in a panic with nightmares about her past. This is your first
session with Jessica, and she shares that she was in an abusive
situation at her elementary school from grades 1-7. It was a
small rural area school with only 1 teacher and less than a
dozen students. Everyone was abused and threatened, but she
suffered the physical beating more often and more brutally. She
reports that she had broken bones, black eyes, and needed
stitches in her head a couple of times. She and the others at the
school never reported what was really happening until she was
in 7th grade and finally told her parents. Her teacher was
arrested and imprisoned with a 16-year sentence and the school
was shut down. She doesn’t understand why she continues to
have difficulty sleeping, eating, and getting close to people
when her parents did everything right after the abuse was
exposed and her life has been very good.
During one session, Jessica is well groomed, dressed in business

7. attire, and her hair and makeup are perfect. She makes good eye
contact during her initial session, and she is logical and
coherent in telling about the past; however, she begins to close
her eyes and hangs on to the chair in your office tightly, as if it
were moving. She cries, sobs, and cannot catch her breath for a
few moments. She begins shaking and appears dazed. You say
her name a few times, and she opens her eyes, calms her
breathing but continues to sob. Jessica continues with telling
you that she has a bachelor’s degree in marketing, a high-paying
job in a large company, and a supportive family. She has a
boyfriend who wants to get married, but she is afraid to commit
to him because she feels like she is “too much work”. She states
that she does not think she is worth close friendships or love
because she cannot give enough back. She avoids most
relationships and tries to just be perfect at work and through her
diet and exercise. She knows that her background has created
this belief but does not have the ability to change it. She shares
that in her early 20’s she drank too much too often but has
given that up and has been sober for 3 years.
Her reason for coming into counseling is because her family and
her boyfriend want closer relationships with her, but she keeps
pushing them away. She wonders if there is something that she
could do so her relationships could become closer and healthier.
Copyright 2020 by University of Phoenix. All rights reserved.
Copyright 2020 by University of Phoenix. All rights reserved.