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Biopsychosocial
Biopsychosocial Form
Please answer all questions to the best of your ability, as it will greatly assist our clinicians in formulating an optimal treatment plan for you. Any information entered into this form is encrypted and transmitted using a HIPAA-certified, secure server.
Patient Name
Your First Name
Your Last Name
Demographic Data
Marital / Relationship Status
Married
Divorced
In a relationship
Single
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White / Caucasian
Multiracial
Are you Hispanic or Latino?
Yes
No
Primary Language
English
Other
Do you speak more than one language?
No (monolingual)
Yes (bilingual or multilingual)
Presenting Problem
Please describe what brings you to IOP Services
Describe any current symptoms that are affecting your quality of life and ability to function
How long have you been experiencing the problem(s) described above?
Less than 30 days
1-6 months
6-24 months
Longer than 2 years
What type of care do you think would best help you? (select all that apply)
Individual Therapy
Group Therapy
Medication Management
Support Group
Intensive Outpatient Program (IOP)
What are your main goals for treatment?
Family & Supporting Relationships
Spouse / Significant Other
if applicable, list name and age, otherwise leave blank
Children
if applicable, list name(s) and age(s), otherwise leave blank
Please Rate your Relationship with your Family
Excellent
Pretty good
Neutral
Not so great
Terrible
1 star = toxic | 2 stars = distant | 3 stars = fine/cordial | 4 stars = good | 5 stars = very close
Are there other people who take on a supportive role in your life?
if applicable, list the name, relationship, and age of each individual
What is your current living situation? Is it expected to change?
eg. alone or with roommates, temporary or somewhat permanent, etc.
Is there a lack of safe housing? (If yes, please explain)
Yes
No
Please explain further
Are you having difficulty with any of the following? (select all that apply)
Completing activities necessary for daily living
Completing tasks at home or at work
Maintaining Relationships with Friends and Family
None of the above
Family History of Illness
Do you have a family history of mental illness? (if yes, please explain further)
Yes
No
Please explain further
Do you have a family history of substance abuse? (if yes, please explain further)
Yes
No
Please explain further
Do you have a family history of any other medical illness? (if yes, please explain further)
Yes
No
Please explain further
Childhood History
Were your parents married?
Yes
No
Did your parents divorce or separate?
Yes
No
How old were you when your parents divorced or separated?
Did either parent remarry?
if so, which parent(s) and when
What was your living situation as a child?
Lived with both parents
Lived with mother
Lived with father
Split time between parents
Lived with other family member
Other
How would you rate your childhood experience?
1 Worst
2
3
4
5 Best
Family Issues: (select all that apply)
Poverty
Domestic violence or abuse
Mental illness
Criminal behavior
None of the above
Trauma History
If you answer yes to any questions in this section, we may ask you to complete another questionnaire (the PCL-5).
Do you have a history of being abused emotionally? (if yes, please explain further)
Yes
No
Please explain further
Do you have a history of being abused sexually? (if yes, please explain further)
Yes
No
Please explain further
Do you have a history of being abused physically? (if yes, please explain further)
Yes
No
Please explain further
Do you have a history of being abused via neglect? (if yes, please explain further)
Yes
No
Please explain further
Do you have a history of being abused via sexual exploitation? (if yes, please explain further)
Yes
No
Please explain further
Have you witnessed abuse? (if yes, please explain further)
Yes
No
Please explain further
Are you currently being abused? (if yes, please explain further)
Yes
No
Please explain further
Medical History
Have you been seen by a Primary Care provider in the past year?
Yes
No
Name of Primary Care Provider
Name of Primary Care Provider
Phone
Phone Number of Primary Care Provider
Date of last appointment with Primary Care Provider
MM slash DD slash YYYY
Date of last appointment with Primary Care Provider
Were you referred to us?
Yes
No
Who referred you?
Doctor / Therapist
IOP Patent
Other
Name of the individual who referred you to us
Name of the individual who referred you to us
Are you currently taking any medications?
Yes
No
Please list the medication name(s), dosage(s), and prescribing provider(s).
Is the medication you're taking effective?
Yes
No
Other
Are you experiencing any side effects from the medication you're taking?
Yes
No
Other
Are you allergic to any medicines?
Yes
No
Please list the medications you are allergic to.
Please list the medications you are allergic to.
Are you currently suffering from any illnesses? (if yes, please explain)
Yes
No
Please explain further
Have you had any major surgeries? (if yes, please explain)
Yes
No
Please explain further
Are you utilizing any alternative medicine approaches? (if yes, please explain)
Yes
No
Please explain further
Do you have any food allergies? (if yes, please explain)
Yes
No
Please explain further
Have you experienced any weight loss or gain, of 10 pounds or more in the last 3 months? (if yes please provide more details)
Yes
No
Please explain further
Have you experienced any decrease in food intake and or appetite recently? (if yes, please explain)
Yes
No
Please explain further
Have you experienced any dental problems recently? (if yes, please explain)
Yes
No
Please explain further
Do you have any eating habits such as bingeing or inducing vomiting? (If yes, please explain and include whether you were referred to us for this)
Yes
No
Please explain further
Do you have an Advanced Directive?
Yes
No
Do you require assistive technology?
Yes
No
What assistive devices, aids, or services do you require
Are you currently in physical pain?
Yes
No
Please rate your pain level from 1 to 10.
Please enter a number from
1
to
10
.
1 = very minor pain | 10 = horrible pain
Psychological History:
Have you ever had feelings or thoughts of suicide?
Yes
No
Do you currently have feelings or thoughts of suicide?
Yes
No
Have you ever had feelings or thoughts of homicide?
Yes
No
History of Symptoms: (select all that apply)
Unable to enjoy activities
Depressed mood
Sleep Disturbance
Change in appetite
General loss of interest
Fatigue
Change in energy level
Change in libido
Problems concentrating
Excessive worry
Excessive guilt
Suspiciousness
Impulsivity
Flashbacks or nightmares
Have you been diagnosed with a behavioral health disorder?
Yes
No
Please explain your diagnosis, as well as past method(s) of treatment for your behavioral health disorder.
Columbia Suicide Severity Scale (C-SSRS)
If you answer "Yes" to either of the first two questions in this section, we may ask you to complete another questionnaire (the SAFE-T).
During the past 30 days, have you wished you were dead or wished you could go the sleep and not wake up?
Yes
No
During the past 30 days, have you had any actual thoughts of killing yourself?
Yes
No
Have you thought about the method in which you might end your life?
Yes
No
Have you had any intention to act on this method?
Yes
No
During the past 3 months, have you ever done anything, started to do anything, or prepared to do anything to end your life?
Yes
No
In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life?
Yes
No
Substance Use
During the past 30 days, have you used tobacco or other nicotine products?
Daily
Weekly
Once or Twice
Never
During the past 30 days, have you had five or more alcoholic drinks in one day?
Daily
Weekly
Once or Twice
Never
During the past 30 days, have you taken prescription drugs more than they were prescribed?
Daily
Weekly
Once or Twice
Never
During the past 30 days, have you used Illicit drugs? (marijuana, cocaine, heroin, etc.)
Daily
Weekly
Once or Twice
Never
Safety Plan
Triggers: Identify situations, behaviors, or areas in your life that could lead to thoughts of self-harm.
Warning Signs: Identify warning signs that indicate that you are starting to struggle with negative thoughts or self-harm.
Lethal Means: Identify objects or areas that you would need restricted to prevent self-harm.
Please list the name(s) and phone number(s) of any social supports that you trust to help decrease your distressed mood.
What coping skills do you utilize or could you utilize to help de-escalate a spiral of negative thoughts or self-harm situation?
Identify coping skills that you can utilize to take your mind off of the problem.
Education and Employment
Education Level
Less than 12 years
High School / GED
Associates Degree
Some College
4-year College Degree
Master's / Professional Degree
Are you currently a student?
Yes
No
Please provide the name of your current school, what year you're in, and if applicable, what degree you're pursuing.
What is your employment status?
Employed
Unemployed
How long have been actively employed for?
How long have you been unemployed?
Are you satisfied with your job?
Yes
No
Are you looking to be employed?
Yes
No
Do you have needs/requirements for employment? Goals or preferences for employment? Are there barriers preventing employment?
Are you meeting your basic needs?
Yes
No
Do you have transportation issues (in going to and from your job and/or anywhere else)?
Yes
No
How does your job affect your mental health?
Yes
No
What is or has been your primary field of employment?
Leave blank if inapplicable to you
Source(s) of Income (select all that apply):
Employment
Retirement
Medical Disability
Public Assistance
SSI or SSDI
Other
Other sources of income
Military History
Have you served or are you currently serving in the military?
Yes
No
Are you currently active in the military?
Yes
No
Please provide your branch of the military and length of service.
Legal History
Do you have any current or pending legal issues?
Yes
No
How are these issues affecting your mental health and/or risk of suicide?
Spiritual & Cultural History
Do you belong to a particular religious or spiritual group?
Yes
No
Please provide the name of the group and your level of involvement.
Do you find your involvement with this group to be helpful with the mental health issues you're facing?
Are there any cultural values or beliefs that you would like for us to be aware of while treating you?
Emergency Contact
Emergency Contact's Name
Emergency Contact's First Name
Emergency Contact's Last Name
Emergency Contact's Relationship to patient
Emergency Contact's Relationship to patient
Emergency Contact's Phone number
Emergency Contact's Phone number
