20 Feb Sample biopsychosocial assessment template: Biological, Psychological, and Social domains
Biopsychosocial Assessment Template
Identifying Information
Client Name:
Age/DOB:
Gender Identity:
Race/Ethnicity/Cultural Background:
Referral Source:
Date of Assessment:
Assessor:
Presenting Problem
Brief summary of the client’s main concerns, symptoms, or issues leading to assessment.
Include client’s own words when possible.
Biological Domain
Medical History: Chronic illnesses, hospitalizations, surgeries, genetic predispositions.
Current Health Status: Vital signs, nutrition, sleep, exercise, pain, disability.
Substance Use: Alcohol, drugs, prescription medications, tobacco.
Developmental History: Prenatal factors, developmental milestones, childhood health.
Family Health History: Relevant hereditary conditions.
Impact on Functioning: How biological factors influence daily life and well‑being.
Psychological Domain
Mental Health History: Previous diagnoses, hospitalizations, therapy, medications.
Current Symptoms: Mood, affect, cognition, thought processes, risk behaviors.
Trauma History: Exposure to abuse, neglect, violence, or other traumatic events.
Coping Skills: Strategies used to manage stress or adversity.
Personality/Identity Factors: Self‑esteem, self‑concept, cultural identity.
Risk Assessment: Suicidal ideation, self‑harm, aggression, impulsivity.
Impact on Functioning: How psychological factors influence relationships, work, school, and daily life.
Social Domain
Family Dynamics: Relationships, communication, support systems, conflict.
Peer/Community Relationships: Friendships, social networks, involvement in groups.
Socioeconomic Status: Employment, income, housing stability, financial stress.
Education/Work: Academic performance, job satisfaction, barriers.
Cultural/Spiritual Factors: Beliefs, practices, values, role of faith.
Environmental Stressors: Discrimination, violence, poverty, systemic barriers.
Access to Resources: Healthcare, social services, community programs.
Impact on Functioning: How social factors influence opportunities, support, and resilience.
Strengths and Protective Factors
Supportive relationships.
Personal resilience and coping skills.
Community involvement.
Cultural or spiritual resources.
Motivation for change.
Summary/Case Formulation
Integrate biological, psychological, and social findings into a holistic understanding of the client.
Identify key risk factors and protective factors.
Highlight how domains interact to shape client functioning.
Recommendations/Plan
Suggested interventions (individual therapy, family therapy, group work, community resources).
Referrals (medical, psychiatric, social services).
Advocacy needs (housing, employment, education).
Goals for treatment and follow‑up.
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