Biopsychosocial Assessment |

James Fitzgerald Therapy, PLLC

James Fitzgerald, MS, NCC, AAP, Psychotherapist

IMPORTANT!

Please do not complete this form unless you have been asked to by your therapist. Most of the information can be gathered during the first few sessions. There are times however, when this questionnaire can be useful or helpful.

Client Intake: Assessments

Biopsychosocial Assessment Questionnaire

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User ID

Your login ID for this website client portal

Date / Time

Date

Time

Presenting Problems

What problems have prompted you to seek therapy?

Rate the intensity of the problems 1 to 10 (1 being mild and 10 being severe)

Selected Value: 0

How are the problems interfering with your day-to-day functioning?

What are your current goals for therapy? If therapy goals were met, what would be different?

Are you currently thinking about suicide or have you ever contemplated suicide?

Yes
No
Prefer not to answer

Thoughts that include a wish to not live anymore with intent and plan.

Are you a trauma survivor?

Yes
No
Prefer not to answer

Including tragic or catastrophic events, and the cumulative effects of traumatic experiences

Are you currently pregnant?

Yes
No
Prefer not to answer

For people with ovaries, leave blank if you don't have a uterus or ovaries.

If Yes, when are you due?

Month/Day/Year

Are you at risk for HIV/AIDS/Sexually Transmitted Diseases?

Yes
No
Prefer not to answer

Are you engaging in unsafe sex, using IV drugs?

Please list any known allergies you have to medications or food:

Has your physical health recently kept you from participating in activities?

Yes
No
Prefer not to answer

Tobacco/Nicotine Use

As new methods of administration (ie, vapors, inhalers, gum, edibles, lozenges) are created, we have had to update this segment.

Have you ever used any forms of tobacco or nicotine? (cigarettes, snuff, vapes, pens, inhalers, etc.)

Yes
No
Prefer not to answer

IF NO SKIP TO NEXT SECTION

Are you a former consumer of tobacco or nicotine? (copy)

Yes
No
Prefer not to answer

How many times on an average day do you use tobacco/nicotine (1-99)?

Cigarettes, Cigars, Snuff, Chewing Tobacco, Pipes, Vapes/Pens, Inhalers

Have you been involved in a program to help you quit using tobacco in the past 30 days?

Yes
No
Prefer not to answer

If Yes, which self-help support group was helpful?

Substance Use and/or Addiction (Present)

The questions in this section refer to the past 30 days.

Would you or someone you know say you have a problem with alcohol?

Yes
No
Prefer not to answer

Would you or someone you know say you have a problem with pills or illegal drugs?

Yes
No
Prefer not to answer

Would you or someone you know say you have problems with other habitual patterns?

Yes
No
Prefer not to answer

i.e., food, gambling, sex, video games, social media, pornography, or shopping?

Have you ever attended a self-help group meeting?

Yes
No
Prefer not to answer

i.e., Alcoholics Anonymous, Narcotics Anonymous, Sex Addicts Anonymous. Out of respect for the 12 step tradition of anonymity, you do not have to answer this question, especially if you are a member of said group.

Substance Use and/or Addiction (History)

The questions in this section refer to any point in the recent past (months) or history (years).

Would you or someone you know say you had a problem with alcohol?

Yes
No
Prefer not to answer

Would you or someone you know say you had a problem with pills or illegal drugs?

Yes
No
Prefer not to answer

Would you or someone you know say you had a problem with other habitual patterns?

Yes
No
Prefer not to answer

Is there a history of substance use disorders, alcoholism, and/or addiction in your family?

Yes
No
Prefer not to answer

If Yes, please describe

Family of Origin, Personal Relationships

You do not have to provide real names, you can use initials or nicknames for clarification

Childhood Experiences: Please tell me about your parents

Are (were) your parents married? Are your parents still alive? What was their relationship like?

Childhood Experiences: Please tell me about your siblings (if you have any)

How many siblings? What was your birth order? What were your relationships like?

Childhood Experiences: Please tell me about your extended family

Grandparents? Aunts and Uncles? Cousins? What were your relationships like?

Has there been any significant person or family member enter or leave your life in the last 90 days?

Yes
No
Prefer not to answer

Have you ever had problems with marriage/relationships?

Yes
No
Prefer not to answer

Do you have 1 or 2 close emotionally intimate friends?

Yes
No
Prefer not to answer

Do you have any close friends?

Yes
No
Prefer not to answer

Do you have problems with friendships?

Yes
No
Prefer not to answer

Do you have problems with other people?

Yes
No
Prefer not to answer

(Superiors, Coworkers, Customers, Vendors, Neighbors)

Do you have children?

Yes
No
Prefer not to answer

If you have children, tell me about them, and your relationship with them.

Family Health History

Is there a history in your family for any of the following diseases or illness? Names or relation to individuals are not required, just the health issues

Other: Please describe any other physical or mental health issues present in your family

Education

What is the highest grade you completed?

Please describe your experiences during your primary education years (K-12)

Did you receive a trade school certificate?

Yes
No
Prefer not to answer

Please describe your experiences during your secondary, post secondary education years.

(Certificate, Associate's, Bachelor's, Master's, Doctorate, Medical)

Legal Issues

Do you currently have unresolved legal issues?

Yes
No
Prefer not to answer

Have you had legal issues in the past?

Yes
No
Prefer not to answer

Summarize your legal issues

Have you ever been arrested? Have you ever been charged and sentenced? Have you been incarcerated? How long? Have you ever been on probation, parole, pre-trial release?

Work History

Are you a student?

Yes
No
Prefer not to answer

Are you retired?

Yes
No
Prefer not to answer

If you are retired, what type of work did you do in the past?

Have you ever served in the military?

Yes
No
Prefer not to answer

Medical History & Information

* Optional (I can gather this information during sessions, however, it may be more convenient to fill out this form). We can discuss the answers in sessions.

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Who is your primary care physician?

Case Manager / Social Worker

Psychiatrist

PCP Phone #

CM/SW Phone #

Psychiatrist Phone #

Have you seen a mental health professional before?

Yes
No
Prefer not to answer

(i.e., Clinical Social Worker, Psychologist, Clinical Mental Health Counselor, Alcohol and Drug Abuse Counselor, Professional Counselor, or Psychotherapist)

If you have, who did you see, when did you see them, and why did you change?

Personal Information

How would you identify your gender?

Gender identity, expression, pronouns

How would you describe your sexual/romantic orientation?

Pan, Bi, Hetero, Homo, etc.

How would you rate your total overall satisfaction with your health and wellness practices (0 to 10)?

Selected Value: 0

0 being the worst, not doing anything at all to address or prevent health concerns, and 10 being the best, doing everything possible to address or prevent health issues or medical problems.

What do you like to do for fun?

(Hobbies, Recreational, Interests, Entertainment, Etc.)

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