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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