CNL-605: Biopsychosocial Assessment Template Client’s Name ✓ Solved

CNL-605: Biopsychosocial Assessment Template Client’s Name:

Client’s Name: Enter client’s name here.

Date: Select or enter the date here.

DOB: Select or enter the client’s DOB here.

Age: Enter the client’s age here.

Start Time: Enter the start time here.

End Time: Enter the end time here.

Identifying Information: [Enter client’s identifying information here.]

Presenting Problem/Chief Complaint: [Enter client’s presenting problem/chief complaint here.]

Substance Use History: [Enter client’s substance use history here.]

Addictions (i.e., gambling, pornography, video gaming): [Enter client’s addictions here.]

Medical History/Mental Health History/Hospitalizations: [Enter client’s medical history, mental health history, and/or hospitalizations here.]

Abuse/Trauma History: [Enter client’s abuse/trauma history here.]

Social History and Resources: [Enter client’s social history and resources here.]

Legal History: [Enter client’s legal history here.]

Educational History: [Enter client’s educational history here.]

Family History: [Enter client’s family history here.]

Cultural Factors: [Enter client’s cultural factors here.]

Resources, Strengths, and Weaknesses: [Enter client’s resources, strengths, and weaknesses here.]

Case Conceptualization: [Enter your case conceptualization here.]

Clinical Justification: [Enter your clinical justification here.]

Initial Diagnosis (DSM-5):

• Principal Diagnosis:
• ICD-10 Code:
• DSM-5 Disorder:
• Subtypes:
• Specifiers:
• Provisional Diagnosis:
• ICD-10 Code:
• DSM-5 Disorder:
• Subtypes:
• Specifiers:

Initial Treatment Goals Informed by Theoretical Orientation (SMART Goal Format):

• Goal # 1:
• Objectives:
• Interventions:
• Target Date:
• Goal # 2:
• Objectives:
• Interventions:
• Target Date:

Student Clinician’s Name: Enter your name here.

Date: Select or enter the date here.

Paper For Above Instructions

In this assessment, we will review a structure for a biopsychosocial assessment, focusing on the client’s specific dimensions that outline their personal, medical, social, and psychological background. This comprehensive tool is vital in understanding the client's past and current functioning levels, aiding clinicians in developing a tailored treatment plan.

Identifying Information: The initial section should outline essential demographic details about the client, such as their name, date of birth, age, and contact information. These details enable efficient tracking and provide the foundational information necessary for further assessment.

Presenting Problem/Chief Complaint: This section captures the client’s primary concerns. It is essential to document the client’s words as closely as possible, detailing their emotional state and specific problems they seek help with, to create a clear picture of the presenting issues that will guide treatment.

Substance Use History: Understanding any substance abuse patterns is crucial for treatment planning. Here, one needs to delve into the type of substances used, frequency, and any prior treatment undertaken. This helps determine the risk factors and informs the clinician about potential obstacles to recovery.

Addictions: Clients may engage in behaviors beyond substance use, such as gambling or compulsive internet use. It’s crucial to explore these behaviors and their impact on the client’s life, offering insight into their overall functioning.

Medical History/Mental Health History/Hospitalizations: A detailed history in this area can reveal patterns and significant events that influence the client's mental health. Documentation should include previous mental health diagnoses, treatments, hospitalizations, and ongoing medical concerns that could impact mental health (American Psychiatric Association, 2013).

Abuse/Trauma History: Exploring a client’s history of trauma or abuse is vital. This section should be approached delicately, as many clients may find it challenging to discuss. Understanding past experiences can help inform therapeutic approaches.

Social History and Resources: This section gathers details about the client’s social environment and support systems. Social networks can heavily influence treatment outcomes, and understanding these dynamics is key (Berkman et al., 2000).

Legal History: Any legal issues or history of incarceration should be documented, as they can represent significant stressors impacting the client's mental health and treatment plan.

Educational History: Educational background can impact a client's self-esteem and employment prospects. Understanding their academic achievements and struggles may provide insights into their cognitive functioning and personal identity.

Family History: Family dynamics play a crucial role in mental health. Documenting mental health issues within the family can reveal hereditary patterns and familial roles affecting client behavior (McGue & Iacono, 2005).

Cultural Factors: Cultural background shapes an individual's worldview. Unpacking cultural influences on the client’s perception of mental health and therapy can improve the therapeutic alliance and outcomes.

Resources, Strengths, and Weaknesses: Every client possesses unique strengths and resources that can aid in treatment. Identifying these can empower clients and promote resilience.

Case Conceptualization: Using a theoretical orientation to conceptualize the client’s problems allows for structured treatment planning. For instance, applying cognitive behavioral therapy principles helps explore faulty cognitive patterns contributing to the client's distress (Beck, 2011).

Clinical Justification: This part should explain why the chosen diagnosis is appropriate based on the client’s symptoms and how these align with DSM-5 criteria.

Initial Diagnosis (DSM-5): Clearly documenting the preliminary diagnosis, including ICD-10 codes, helps in creating a targeted treatment plan and justifying the clinical approach.

Initial Treatment Goals: Using the SMART criteria (Specific, Measurable, Achievable, Relevant, Time-bound) for crafting treatment goals ensures clarity and a focused approach to therapy.

Ultimately, the biopsychosocial model allows clinicians to understand the complex interplay of various factors influencing a client’s mental health. The resulting treatment plan can then be holistic, addressing the multifaceted nature of mental health disorders.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social Science & Medicine, 51(6), 843-857.
• Beck, A. T. (2011). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press.
• McGue, M., & Iacono, W. G. (2005). The association of parental divorce with adolescent substance use: A behavioral genetic analysis. Developmental Psychology, 41(1), 11-22.
• Whitley, R., & Wang, J. (2019). The social determinants of mental health: A complex interplay. American Journal of Public Health, 109(S1), S68-S75.
• Rustemeyer, R., & Humble, D. M. (2020). The biopsychosocial model in mental health: The case for an integrative approach. Psychology and Health, 35(9), 1096-1110.
• U.S. Department of Health and Human Services. (2015). Mental health: A report of the surgeon general. Washington, DC: Government Printing Office.
• Fava, G. A., & Tomba, E. (2009). Mental health and quality of life: A guide for the therapist. The Clinical Psychologist, 13(1), 1-8.
• Katon, W. J., & Sullivan, M. D. (1990). Depression and pain comorbidity. Archives of Internal Medicine, 150(4), 1055-1060.
• Gonzalez, J. S., et al. (2016). The role of psychosocial factors in diabetes management and control: A review of the literature. American Diabetes Association, 39(12), 884-895.