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Free Biopsychosocial Assessment Form Template

Free Biopsychosocial Assessment Form

Name: Free Biopsychosocial Assessment Form Template
Brand: Template.net
Availability: InStock

Biopsychosocial Assessment Form

Please answer the following sections completely to ensure a thorough assessment.

Client Information

Name

Date of Birth

Email

Phone number

Assessment

Problem

Please provide a description of the problem you are facing.

How long have you been dealing with this problem

Less than a month
1 - 3 months
3 - 6 months
6 months - 1 year
1 - 2 years

How would you rate the intensity of this problem?

Have you experienced any of the following in the past 2 weeks?

Anxiety
Difficulty Sleeping
Lack of Energy
Appetite Changes
Guilt
Hearing Things
Feelings of Hopelessness
Loss of Interest in Activities

How would you describe your current mood?

Please select one or more.

Sad
Anxious
Irritable
Happy
Calm

Do you have thoughts of harming yourself or others?

Are you dealing with substance abuse?

If yes, please specify:

Are you pregnant?

Who do you live with?

Alone
Family
Partner
Friends

Do you have a strong support network?

Describe the relationship you have with your family.

Are there any issues at home affecting your well-being?

If yes, please describe:

Detail current medical conditions, surgeries, and allergies (if any)

Are you taking any medications?

If yes, please list down:

Have you had any hospitalizations in the past year?

If yes, please detail:

What do you expect to achieve from your therapy sessions?

Anything else you would like to share that may help us better understand your situation?

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Conduct comprehensive assessments with the Biopsychosocial Assessment Form Template available on Template.net! This form is designed to capture physical, psychological, and social health factors with editable sections for customized data collection. The customizable format allows for modifications to fit specific therapeutic settings. Use the AI Editor Tool to make quick updates and ensure accurate, individualized assessments for each client!