Professional Documents
Culture Documents
BIOPSYCHOSOCIAL ASSESSMENT
CONSUMER INFORMATION
Consumer Name:
Case #:
Assessment Date:
Start Time:
Stop Time:
PRESENTING PROBLEMS
Accommodations necessary to complete assessment: Explain:
What brings you in for services?
Yes
No
Court System
Schools
SSA
Vocational
PERSONAL/FAMILY INFORMATION
Mothers name:
BIOPSYCHOSOCIAL ASSESSMENT
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Other
Consumer Name:
Case #:
Married
Separated
Living Together/Unmarried
Never Married
Unknown
Divorced
Other
Comments:
List Siblings:
Significant Other:
Have you ever been married?
How many times?
Yes
No
Yes
No
If currently married or involved in significant relationship, how long and what is the status of the
relationship?
Are you pregnant or do you suspect you may be pregnant?
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Yes
No
Consumer Name:
Case #:
Children:
Childs Name
Age
Male
Female
Male
Female
Male
Female
Male
Female
Yes
No
Yes
No
Yes
No
Yes
No
BIOPSYCHOSOCIAL ASSESSMENT
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Biological Child
Consumer Name:
Case #:
Consumer Name:
Case #:
PERSONAL/FAMILY INFORMATION:
Need/Desire/Concern
No Need/Desire/Concern
CHILDHOOD
At what age did the following developmental milestones occur? (Optional for adults)
Unknown
Not Applicable
Walk:
Age:
Within developmental milestones?
Yes
Talk:
Age:
Within developmental milestones?
Yes
Toilet Trained:
Age:
Within developmental milestones?
Yes
Good
Yes
Fair
Did you ever live outside your parents home for an extended time?
Explain:
BIOPSYCHOSOCIAL ASSESSMENT
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No
Unknown
Poor
Yes
No
Unknown
Consumer Name:
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Case #:
Consumer Name:
Case #:
CHILDHOOD:
Need/Desire/Concern
No Need/Desire/Concern
RESIDENTIAL
Residential Living Arrangement
Homeless on the street or in a shelter for the homeless.
Living in a private residence with natural or adoptive family member(s).
Living in a private residence not owned by the CMHSP or the contracted provider, alone or with spouse
or non-relative(s).
Foster Family Home
Specialized Residential Home
General Residential Home
Prison/Jail/Juvenile Detention Center
Nursing Care Facility
Institutional Setting (Congregate Care Facility, Boarding School, Child Caring Institutions, State
Facilities).
Supported Independence Program (Lease is held by CMHSP or Provider).
Number of beds in residential setting:
Unknown
1-3
4-6
7-15
16+
RESIDENTIAL INFORMATION:
Need/Desire/Concern
No Need/Desire/Concern
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
EDUCATION
Highest Level Attended:
Completed less than high school
Completed special education, high school or GED
In school Kindergarten through 12th grade
Highest grade: (Select a grade)
K Kindergarten
01-First Grade
02-Second Grade
04-Fourth Grade
05-Fifth Grade
06-Sixth Grade
08-Eighth Grade
09-Ninth Grade
10-Tenth Grade
12-Twelfth Grade
In Training Program
In Special Education
Emotionally Impaired (EI)
Cognitive Impaired (CI)
Severely Multiply Impaired (SXI)
Autistic Impaired (AI)
Health Impaired (HI)
Not Applicable
Attended or is attending Undergraduate College
College Graduate
03-Third Grade
07-Seventh Grade
11-Eleventh Grade
Yes
No
Truancy
Fair
Good
Yes
No
EDUCATION INFORMATION:
Need/Desire/Concern
No Need/Desire/Concern
Other
Poor
Consumer Name:
Case #:
Please rank your skills in the following areas as they relate to your current living situation.
Area
1-Independent
2-Guide/Direct
3-Provide/Assist
4-Not Age
Appropriate
Eating/Feeding:
Toileting:
Bathing:
Dressing:
Grooming:
Transferring:
Ambulation/Mobility:
Medication Administration:
Laundry:
Cooking:
Transportation:
Housecleaning:
Paying Bills:
Leisure/Recreation:
Community Access:
Explain any current assistance by family members, friends and/or providers for the above identified areas
including leisure:
Are there adequate assets, income and/or insurance(s) to meet your needs?
Explain:
BIOPSYCHOSOCIAL ASSESSMENT
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Yes
No
Consumer Name:
Case #:
MILITARY
Section does not apply
Have you been involved in the military?
Yes
No
Yes
No
General
MILITARY
Need/Desire/Concern
No Need/Desire/Concern
EMPLOYMENT
Employment Status:
Employed full time (30 hours or more per week) competitively or self employed
Employed part time (less than 30 hours per week) competitively or self employed
Unemployed looking for work, and/or on lay-off from job
Not in the competitive labor force
Includes: homemaker, student age 18 and over, day program participant, resident or inmate of an
institution (including nursing home)
Retired from work
Sheltered workshop or work services participant in non-integrated setting
Not applicable to the person (e.g., child under 18)
In supported employment only
In supported employment and competitive employment
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
In unpaid work
If employed, occupation:
Minimum wage: Yes
No
N/A
Work Experience:
Where do you work?
How many hours per week?
How long at current paid or volunteer job?
Yrs
Months
How many paid or volunteer jobs have you had in the past 2 years?
Have you ever had problems at paid or volunteer work?
Are you satisfied with your current paid or volunteer work?
Yes
Yes
No
No
If you are not working, are you interested in pursuing any kind of community employment or volunteer
work?
Yes
No
Explain:
EMPLOYMENT
Need/Desire/Concern
No Need/Desire/Concern
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
GUARDIAN/LEGAL
Phone Home:
Family Guardian
Parental
Permanent State Wardship
Public Guardian
Temporary Wardship
Relationship to Consumer:
Co-Guardian Information:
Co-Guardian Name:
Address:
Phone Work:
Type of Guardianship:
Phone Home:
Family Guardian
Parental
Permanent State Wardship
Public Guardian
Temporary Wardship
Relationship to Consumer:
Additional Guardian Notes:
Yes
No
Yes
Yes
No
No
BIOPSYCHOSOCIAL ASSESSMENT
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Yes
No
Consumer Name:
BIOPSYCHOSOCIAL ASSESSMENT
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Case #:
Consumer Name:
Case #:
Yes
No
Comments:
GUARDIAN/LEGAL:
Need/Desire/Concern
No Need/Desire/Concern
Consumer Name:
Case #:
items in pictures
Minimal difficulty-Sees large print, but not regular print in newspapers/books or cannot identify large
objects in pictures
Moderate difficulty-Limited vision; not able to see newspaper headlines or small
items in pictures, but can identify objects in his/her environment
Severe difficulty-Object identification in question, but the persons eyes appear to follow objects, or the
person sees only light, colors, shapes
No vision
Visual appliance used
Yes
No
Health Conditions
Indicate whether or not the individual had the presence of each of the following health conditions, as
reported by the individual, a health care professional or family member, in the past 12 months.
Pneumonia (2 or more times within the past 12 months)-including Aspiration Pneumonia
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Asthma
Never present
History of condition, but not treated within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Upper Respiratory Infections (These infections may affect the throat, nasal cavity, sinuses, larynx or
bronchi. (3 or more times within the past 12 months)
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Gastroesophageal Reflux, or GERD
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Chronic Bowel Impactions
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Consumer Name:
Case #:
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Seizure disorder or Epilepsy
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months and seizure free
Treated for the condition within the past 12 months, but still experiencing occasional seizures (less
than one per month)
Treated for this condition within the past 12 months, but still experiencing frequent seizures
Information unavailable
Progressive neurological disease, include dementia, Alzheimers and Parkinsons disease.
Not present
Treated for the condition within the past 12 months
Information unavailable
Diabetes, include both Diabetes Type I and Diabetes Type II-(Insulin Dependent)
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Hypertension
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for condition within the past 12 months and blood pressure is stable
Treated for condition within the past 12 months, but blood pressure remains high or unstable
Information is unavailable
Obesity
Not present
Medical diagnosis of obesity present or Body Mass Index (BMI) >30
(if 30 lbs. or more overweight)
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Consumer Name:
Case #:
MEDICAL/MEDICATIONS
Do you have a primary care physician?
Yes
No
Qualified Health Plan (QHP):
Great Lakes Health Plan
Health Plan of Michigan
Health Plus
Partners
McLaren Health Plan
Midwest Health Plan
Molina Healthcare of MI
If Yes, Physician Name/Address/Phone Number:
Date last seen:
If you do not have a primary care physician, do you want or need help finding one?
Yes
QTY/Refills
Instructions:
Instructions
D/C
Drug
Name/Strength
Yes
No
N/A
Yes
No
N/A
Allergies to medication?
Check here if you would like to show this as a Health and Safety warning.
Date of last physical: (Actual/Approximate/Unknown)
BIOPSYCHOSOCIAL ASSESSMENT
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No
Consumer Name:
Case #:
Major Illnesses/Surgeries:
Accidents/Major Injuries:
Hospitalizations (psychiatric):
Yes
No
Medical/Medications
Need/Desire/Concern
No Need/Desire/Concern
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
LETHALITY ASSESSMENT
Past
Ideation
Intent
Plan
Means
Action
None
Current
Ideation
Intent
Plan
Means
Action
None
Others
Ideation
Intent
Plan
Means
Action
None
Ideation
Intent
Plan
Means
Action
None
Property
Ideation
Intent
Plan
Means
Action
None
Ideation
Intent
Plan
Means
Action
None
Self
Explain:
Explain:
Explain:
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
Yes
Yes
Is there a Family History of Mental Illness, Developmental Disability and/or Substance Use Disorder?
No Family History
Family Member
MI
DD
SUD
Diagnosis
Yes
Yes
No
No
Yes
No
BIOPSYCHOSOCIAL ASSESSMENT
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Yes
No
Consumer Name:
Case #:
(A yes answer to any of these questions is likely to indicate drug abuse and should spur further investigation)
Complete ASAM worksheet if applicable.
Comments:
Narrative:
SUD CHART
Section applicable:
If yes, please complete SUD Chart form #1018.
No
Mental Health and SUD History:
Need/Desire/Concern
No Need/Desire/Concern
What are the past recovery attempts? Longest period of recovery? How was this achieved?
Did you have a relapse? What triggered the relapse? What will be different in treatment this time? Any use
of Antabuse, Methadone, Maltraxone or Revia?
What are the supports experienced in the past? AA/NA meetings, sponsor, support groups, therapy
support, group or church?
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
Have you engaged in high risk sexual behavior (number of sexual partners, use of barriers or condoms)? If yes,
when did you first become sexually active?
Are you more sexually active when using mood altering chemicals?
Mental Status
Mental Status
Appearance:
Comments:
Remarkable
Unremarkable
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Attitude:
Comments:
Behavior:
Comments:
Case #:
Remarkable
Remarkable
Mood/Affect:
Comments:
Orientation:
Comments:
Unremarkable
Remarkable
Motor Activity:
Comments:
Judgment:
Comments:
Unremarkable
Unremarkable
Remarkable
Remarkable
Remarkable
Insight:
Remarkable
Comments:
Thought Process:
Comments:
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Remarkable
Unremarkable
Abstract Reasoning:
Comments:
Remarkable
Unremarkable
Language Function:
Comments:
Remarkable
Unremarkable
Memory:
Comments:
Remarkable
Unremarkable
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Consumer Name:
Case #:
Cognitive Functioning:
Remarkable
Unremarkable
Comments:
Perception:
Remarkable
Unremarkable
Comments:
Comments:
MENTAL STATUS:
Need/Desire/Concern
No Need/Desire/Concern
DIAGNOSIS
Axis I (ICD-9 and DSM-IV):
Axis II (ICD-9 and DSM-IV):
Axis III:
Axis IV:
Economic problems
Problem with primary support group
Problem accessing healthcare
Problem related to social environment
Educational problems
Problem related to interaction with
legal system
Occupational problems
Housing problems
Other psychological and environmental
problem
Axis V: Current GAF
Date:
Diagnostic Summary:
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
SERVICES/SUPPORT RECOMMENDATIONS
Assessment of consumer/natural support system to manage involvement with systems and ensure necessary
supports:
Independent
Strong Abilities
Moderate Abilities
Limited Abilities
Recommendations regarding Case Management /Supports Coordination:
Necessary
Unnecessary
Strengths:
Recommendations:
The following domains have been identified as a need/desire/concern.
The above domains will be discussed during the Person Centered Planning process to determine what resources might be
available to address the area, what, if any, CMH/PIHP service might be medically necessary, as well as the amount, duration and
scope of such service.
BIOPSYCHOSOCIAL ASSESSMENT
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Consumer Name:
Case #:
Staff Signature
Date
Date
BIOPSYCHOSOCIAL ASSESSMENT
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