*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
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- Britney McCarthy
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1 BIOPSYCHOSOCIAL ASSESSMENT B page 1 of 5 / Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding of the problems for which you are seeking help and of other important events in your life. WHO REFERRED YOU TO LAUREATE? TODAY S DATE WHAT FACTOR(S) LED YOU TO SEEK CHEMICAL DEPENDENCY TREATMENT AT THIS TIME? Legal problems Health problems Relationship problems School problems DATE OF TREATMENT SUBSTANCE ABUSE MOTIVATION FOR CHANGE Financial problems Other - Work problems PREVIOUS TREATMENT TELL US ABOUT YOUR PREVIOUS MENTAL HEALTH OR SUBSTANCE ABUSE TREATMENT MENTAL HEALTH NAME OF TREATMENT PROVIDER OR CENTER Depression Anxiety Compulsive gambling Compulsive sex or pornography Drug dealing Eating disorder SUBSTANCE USE HISTORY EXPLAIN TYPE OF TREATMENT (Residential, Detox, Outpatient, etc.) WHILE USING ALCOHOL OR DRUGS, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING MENTAL HEALTH OR BEHAVIORAL PROBLEMS? SUBSTANCES ALCOHOL (including beer and wine) DEPRESSANTS (Valium, Xanax, etc.) STIMULANTS (Speed, Meth, etc.) COCAINE (Powder, Crack, etc.) MARIJUANA (Any form) HALLUCINOGENS (Acid, Mushrooms, Ecstasy) INHALANTS (Poppers, paint, glue, etc.) OPIATES (Pain meds, heroin, etc.) NICOTINE (Smoked, smokeless, etc.) FIRST USED DATE LAST USED CURRENT CRAVING INTENSITY (ne, moderate or strong) RESPONSE TO TREATMENT (How long did you stay sober?) PATTERN OF USE (How much, how often) PREVIOUS PATTERN FREQUENCY AND QUANTITY CURRENT PATTERN FREQUENCY AND QUANTITY
2 BIOPSYCHOSOCIAL ASSESSMENT B page 2 of 5 / CONSEQUENCES OF SUBSTANCE USE Have you ever had work or school problems related to alcohol or drug use? Has alcohol or drug use ever had a negative impact on any of your relationships? Have you ever had legal charges related to your alcohol or drug use? Has alcohol or drug use ever led to any medical conditions? Has alcohol or drug use ever caused you any financial problems? OBSTACLES TO RECOVERY DO YOU BELIEVE ANY OF THE FOLLOWING WILL MAKE IT MORE DIFFICULT FOR YOU TO STOP USING ALCOHOL OR DRUGS? Living with someone who uses alcohol or drugs Having friends who use alcohol or drugs Experiencing a great deal of job stress Being depressed or anxious Having strong cravings for alcohol or drugs Having few or no hobbies or interests DO YOU HAVE ANY COMMUNICATION DIFFICULTIES WHICH COULD AFFECT YOUR RECOVERY EFFORT (IE SPEECH, VISUAL, OR HEARING IMPAIRMENTS)? IF SO - WHAT? DURING TREATMENT, WHAT SUPPORT SYSTEMS (FAMILY, FRIENDS, NEIGHBORS, CHURCH, ETC.) WILL BE AVAILABLE TO HELP YOU WITH YOUR SUBSTANCE ABUSE PROBLEM? PROBLEMS EXPERIENCED DURING CHILDHOOD OR ADOLESCENCE Delayed speech Delayed motor development Excessive shyness Excessive aggression Hyperactivity Learning problems Poor peer relationships Alcohol or drug abuse Depression School failure / dropout Runaway behavior Illegal activities Sexual abuse Physical abuse Abusing someone sexually Abusing someone physically CHILDHOOD DEVELOPMENTAL HISTORY CHECK ONE IF YES - DESCRIBE YES NO FAMILY HISTORY LIST ANY FAMILY MEMBERS BELOW WHO HAVE BEEN TREATED FOR MENTAL HEALTH OR SUBSTANCE ABUSE PROBLEMS FAMILY MEMBER (Parents, grandparents, siblings) TYPE OF PROBLEM OR DISORDER TYPE OF TREATMENT (Hospitalization, medication, etc.) DESCRIBE ANY SIGNIFICANT CHILDHOOD EVENTS THAT YOU THINK MIGHT BE IMPORTANT TO UNDERSTAND YOUR CURRENT PROBLEM
3 INTENSIVE OUTPATIENT PROGRAM BIOPSYCHOSOCIAL ASSESSMENT B page 3 of 5 / MARITAL STATUS ENVIRONMENT AND HOME SEXUAL ORIENTATION WHO LIVES IN YOUR HOME WITH YOU? Single Married LIST NAMES OF YOUR CHILDREN Living as married Divorced WHO HAS CUSTODY? WHAT CHILDCARE ARRANGEMENTS DO YOU HAVE? HOW MANY CLOSE FRIENDS DO YOU HAVE? ARE YOU SATISFIED WITH THIS NUMBER? HAS THERE BEEN VIOLENCE / PHYSICAL / SEXUAL ABUSE IN YOUR CURRENT RELATIONSHIPS? IF THERE IS SIGNIFICANT INFORMATION REGARDING YOUR SEXUAL HISTORY - LIST HERE WHERE ARE YOU EMPLOYED? HAVE YOU BEEN IN THE MILITARY? HIGHEST LEVEL OF EDUCATION Did not complete high school Obtained GED VOCATIONAL, EDUCATIONAL AND MILITARY HISTORY IF YES - BRANCH IS SPIRITUALITY A SIGNIFICANT PART OF YOUR LIFE? - WHAT GIVES YOUR LIFE MEANING? CURRENT LEGAL PROBLEMS - DESCRIBE PAST LEGAL CHARGES - DESCRIBE CURRENT FINANCIAL PROBLEMS - DESCRIBE LIST ANY INTERESTS OR HOBBIES WHAT SOCIAL ACTIVITIES DO YOU PARTICIPATE IN? WHAT IS YOUR ETHNIC GROUP? African American Native American Asian Caucasian FINANCIAL AND LEGAL STATUS LEISURE AND RECREATION ETHNIC AND CULTURAL INFORMATION Hispanic Other - JOB TITLE HIGHEST RANK WHAT, IF ANY, CULTURAL BELIEFS DO YOU HAVE THAT COULD BE RELEVANT TO YOUR TREATMENT? Completed college Technical training Completed high school Completed graduate school RELIGION AND SPIRITUAL ORIENTATION WHAT DENOMINATION ARE YOU AFFILIATED WITH - IF ANY YOUR PAST RELATIONSHIPS? TYPE OF DISCHARGE DO YOU LIKE YOUR JOB? DO YOU ATTEND REGULARLY? WHAT ARE YOUR STRENGTHS, SUCH AS TALENTS, SKILLS OR PERSONAL CHARACTERISTICS?
4 INTENSIVE OUTPATIENT PROGRAM BIOPSYCHOSOCIAL ASSESSMENT B page 4 of 5 / WHO IS YOUR PRIMARY CARE PHYSICIAN? BIOMEDICAL SCREENING LIST YOUR PSYCHIATRIST - IF ANY DESCRIBE ANY CHRONIC PAIN YOU MAY EXPERIENCE CHECK ANY OF THE MEDICAL CONDITIONS BELOW WHICH YOU HAVE HAD Chronic headaches HIV / AIDS Chronic stomach pains High blood pressure Numbness Chest pain Eye disease Bronchitis Erectile dysfunction Hearing loss HOW LIKELY IS IT THAT ANY OF THE ABOVE ARE RELATED TO YOUR ALCOHOL OR DRUG USE? GYN problems Weight gain Blackouts Heart problems Cirrhosis WHICH OF THE FOLLOWING OCCUR WHEN YOU DISCONTINUE USING ALCOHOL OR DRUGS - CHECK ALL THAT APPLY Depressed mood Nausea or vomiting Sweating Racing pulse Insomnia Hallucinations Extreme anxiety Seizures Fever GOALS FOR TREATMENT PLEASE INDICATE WHICH ONE OF THE FOLLOWING MOST APPLIES TO YOU AT THIS TIME I think that total abstinence from alcohol and drugs is the only answer for me, and I want to stop drinking and using completely. I think that total abstinence from alcohol and drugs may be necessary for me, but I am not sure. If I knew that controlled drinking and using were impossible for me, then I would want to stop drinking and using completely. I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a light social non-problem level. I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a moderate social non-problem level. I think that total abstinence is not necessary for me, but I would like to reduce my drinking and using to a heavy social non-problem level. I think that total abstinence is not necessary for me, and I see no need to reduce my drinking and using. IS THERE ANY INFORMATION THAT YOU WANT STAFF MEMBERS TO KNOW ABOUT YOU? Blood disorder Tuberculosis Hepatitis Venereal disease Weight loss Dilated pupils Diarrhea Hand tremors HAVE YOU EVER ATTEMPTED SUICIDE? DO YOU CONSIDER YOURSELF A HIGH RISK TO ATTEMPT SUICIDE IN THE FUTURE? DO YOU CONSIDER YOURSELF OR ANY FAMILY MEMBER A SERIOUS THREAT TO DO HARM OR BE HARMED BY SOMEONE?
5 BIOPSYCHOSOCIAL ASSESSMENT B page 5 of 5 / FOR STAFF USE ONLY BELOW THIS LINE PATIENT HAS BEEN INFORMED OF THE NEED AND BENEFIT OF FAMILY OR SIGNIFICANT S PARTICIPATION IN WEEKLY FAMILY GROUP? IF APPLICABLE, PATIENT MADE AWARE OF THE POSSIBLE RELATIONSHIP BETWEEN PATTERN OF SUBSTANCE USE AND IDENTIFIED MEDICAL CONDITIONS IF APPLICABLE, PATIENT INFORMED OF NEED FOR PHYSICAL EXAMINATION LEVEL OF CARE RECOMMENDATION OUTPATIENT withdrawal risk biomedical complications emotional / behavioral complications INTENSIVE OUTPATIENT Minimal risk of severe withdrawal or manageable biomedical conditions Mild emotional / behavioral conditions requiring monitoring Cooperative but needs motivation Needs minimal support for abstinence Supportive recovery environment Resistance moderate but requires structured program Likelihood of relapse without close monitoring and support INPATIENT Severe withdrawal requiring medical monitoring Requires inpatient diagnosis and treatment Dual diagnosis requires 24-hour psychiatric and addiction treatment TREATMENT ACCEPTANCE LEVEL Withdrawal symptoms require medical treatment - referred to Inpatient Some resistance, requires structured program - referred to Intensive Outpatient Program Cooperative but needs motivating and monitoring strategies - referred to Outpatient ADDITIONAL STAFF COMMENTS - IF APPLICABLE Environment is non-supportive but patient can cope in structured program REVIEWED BY - PRINT CLINICIAN S SIGNATURE CREDENTIALS DATE
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