Biopsychosocial Interview

Name:	
Address:
DOB:                                                      
Age:	
Phone Number(s):
Sex:                      
Ethnicity: 	
Marital Status:
Referral Source:	
Today’s Date:

Presenting Concerns

Reason for Referral:

What symptoms are you experiencing?

How is this affecting your ability to function?

Duration of symptoms:

Social History

Who else lives there?

Do you have children?  
How is your relationship? 

Siblings and parents? 
How is your relationship?

History of family mental health or substance abuse?



Social Supports:

Friendships/social/ pets/ peer supports relationships

Meaningful activities:

Religion/Spirituality:

Community Supports/Self Help Groups?

Legal History

Do you have a legal guardian, representative payee, conservatorship, or special needs trust?      
Yes          
No

Name

Have you ever been convicted of a crime?
Yes	
No	
Past	
Present


Education

Highest grade completed:
Major:

Have you ever received any special education resource services?

Are you currently in school?      
Yes   or    
No  
     
Year graduated  
HS
College

Employment:

Are you employed?
Hours per week

Why are you unemployed?

Military:

Have you or family members served in the military?


Trauma

Physical abuse/Neglect	
Emotional/verbal abuse	
Sexual abuse/molestation	
Domestic violence	
Community violence: Exposure to intentional acts of interpersonal violence committed in public areas by individuals who are not intimately related to the victim.
Witness to violence	
Other	

Flashbacks
Yes
No

Nightmares
Yes
No

Avoidance: behaviors are any actions a person takes to escape from difficult thoughts and feelings.
Yes
No  
 
Feelings of detachment	 
Yes        
No
 
Sleep disturbance	 
Yes        
No
 
Hypervigilance: highly or abnormally alert to potential danger or threat
Yes        
No  
   
Exaggerated startle response	 
Yes        
No
 
Behavioral Health History:

Hospitalizations:

Dates of treatment
Reason for hospitalization
Hospital
What was helpful?

Counseling or Psychiatrist:

Dates of treatment
Reason/Diagnosis
Provider/Agency	
What was helpful?

Substance Use:

In past 12 months:
Frequency/
most recent use	
Type	
Age at first use/
Route

Illegal/prescription drug use	
Yes                
No  		
	
Tobacco	
Yes
No		

Alcohol	
Yes
No
			
Cannabis
Yes
No			

Treatment for substance abuse

Dates of treatment
Provider/Agency	
Reason                                                  	
Age of first use
 
Suicidal/Homicidal Ideation

Do you ever think about dying?	
Y       
N

Do you ever think about killing yourself or wishing you were dead?
Y
N

Viable suicide plan – If you do think about suicide, do you have a plan about how to do it?
Y
N 

Available means for suicide	 
Y        
N 

Previous suicide attempts
Y
N
How many?
Most Recent?

Current homicidal ideation
Y
N 

Previous intimidation
Y
N 

History of violence
Y
N 

Identifiable victim(s)
Y
N 

Available means
Y
N 

Past Risk and Alerts

Self-harm
Y
N 

Losses in last 2 years
Y
N 

Anniversary reactions to losses over lifetime
Y
N 

Imminent stressors
Y
N 

Difficulty managing anger
Y
N 

Destructive to property
Y
N 

Violent towards a person
Y
N 

** Result in injury
Y
N

** Weapon involved
Y
N

**Influenced by drugs or alcohol
Y
N

Psychotropic Medications:

Mood

Depressed Mood
Y
N 

Hopelessness
Y
N 

Worthlessness
Y
N 

Loss of interest
Y
N 

Guilt
Y
N 

Isolation
Y
N 

Appetite Change
Y
N 

Weight Change
Y
N 

Cries easily
Y
N 

Lack of concentration
Y
N 

Indecisiveness
Y
N 

Fatigue/loss of energy
Y
N 

Grandiosity: exaggerated belief in self-importance
Y
N

Pressured Speech: accelerated speech sometimes too fast to understand
Y
N

Racing thoughts: fast moving and often repetitive thought patterns that can be overwhelming. They may focus on a single topic, or they may represent multiple different lines of thought.
Y
N

Easily distracted
Y
N 

Increased energy
Y
N 

Increased/goal directed activity
Y
N 

Risky or dangerous behavior
Y
N 

Hypersexuality: dysfunctional preoccupation with sexual fantasy, often in combination with the obsessive pursuit of casual or non-intimate sex; pornography; compulsive masturbation
Y
N 

Anxiety

Excessive worry
Y
N 

Restlessness
Y
N 

Fear of social interactions
Y
N 

Panic attacks
Y
N 

Recurrent/ persistent thoughts
Y
N 

Repetitive or ritual behaviors
Y
N 
 
Thought

Visual hallucinations
Y
N 

Auditory Hallucinations
Y
N 

Paranoia
Y
N 

Delusions: unshakable beliefs in something that isn't true or based on reality.
Y
N
____ control
___thought withdrawal
___thought insertion
___thought broadcasting
___persecution
___reference
___grandeur
___somatic
___erotic
___religious
___other:  

Assessment/ Plan

STRENGHTS/INTERESTS/COMMUNITY INVOLVEMENT

Life goals 

Strengths
1.
2.
3.
4.

Abilities 

Past achievements

Mental Status Exam:

Appearance:
__wnl
___well-groomed
___unkempt
___disheveled
___underdressed
__overdressed
___soiled
___revealing
___appears older than age
___appears younger than age
___other:

Build/Stature:
___wnl
___thin
___overweight
___short
___tall
___ other:

Posture:
___wnl
___slumped
___rigid
___tense
___atypical
___other: 

Eye Contact:
___average
___avoidant
___intense
___intermittent
___other:

Activity:
___wnl
___accelerated
___slowed
___stereotyped/peculiar
___impulsive
___agitated
___hyperactive
_fidgety
__tics
__tremors
__pacing
__picking
___other:

Attitude towards examiner:
___cooperative
___hostile
___defensive
___evasive
___anxious
___seductive
___mistrustful
___demanding
___manipulative
___ingratiating
___confused
___interested
___indifferent
___apathetic
___despondent
___angry
___other: 

Attitude towards parent/guardian:
___N/A
___positive interaction
___ignores parents
___disrespectful
___demanding
___immature
___lack of spontaneity
___other:

Separation (for children/adolescent):
___N/A
___unremarkable/age appropriate
___clingy to parent/guardian, but separates
___cannot separate
___disinhibited/does not care
___other:

Mood:
___euthymic
___depressed
___anxious
___angry
___euphoric
___irritable
___silly
___other:

Affect:
___full
___constricted
___flat
___inappropriate
___labile
___other:

Speech:
___clear
___slurred
___rapid
___pressured
___over productive
___underproductive
___echolalic
___poverty of speech
___other:

Thought Process:
___logical
___circumstantial
___tangential
___loose
___racing
___incoherent
___coherent
___concrete
___blocked
___flight of ideas
___poverty of content
___slowed thinking
___derailment 

Perception:
___wnl
___illusions
___depersonalizations
___derealization
___reexperiencing
___other:

Hallucinations:
___denied
___none evidenced
___auditory
___command
___visual
___olfactory
___tactile
___gustatory
___other: 

Thought Content:
___wnl
___preoccupation/ruminations
___obsessional
___depressive
___paranoid
___self-deprecatory
___grandiose
___phobic
___compulsion
___fear of harm
___poverty of thought
___other:

Delusions:
___none reported
___control
___thought withdrawal
___thought insertion
___thought broadcasting
___persecution
___reference
___grandeur
___somatic
___erotic
___religious
___other:  

Cognition:
___wnl  

Impairment of:
___attention/concentration
___ability to abstract
___fund of knowledge
___visuospatial ability
___reading and writing
___ calculation
___other:

Impairment of:
___Orientation
___person
___place
___time
___situation

Impairment of:
___Memory
___short term
___long term
___erratic/inconsistent

Intelligence estimate:
___average
___above average
___borderline
___mental retardation

Insight:
__wnl
___minimal insight
___partial insight
___mostly blames others 

___difficulty acknowledging presence of substance abuse problems
___difficulty acknowledging presence of psychiatric problems

Judgment:
___wnl  

___impaired ability to make reasonable decisions
___mild
___moderate
___severe

PRELIMINARY DSM V DIAGNOSIS

Axis I:

REFERRALS MADE

__None at this time
__Psychiatric
__Substance Use
__Medical
__Other_______________