Biopsychosocial Assessment: Part 1

Refer back to the movie you selected and watched or the case study you read during Topic 1. Consider the character you selected or the person from the case study and complete a biopsychosocial assessment about your selected person using the provided biopsychosocial template. Only complete Part 1 of the template, as Part 2 will be completed later in the course.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.

This assignment meets the following CACREP Standard: 2.F.5.g: Essential interviewing, counseling, and case conceptualization skills.

This assignment meets the following NASAC Standards:

25) Gather data systematically from the client and other available collateral sources, using screening instruments and other methods that are sensitive to age, culture and gender. At a minimum, data should include: current and historic substance use; health, mental health, and substance-related treatment history; mental status; and current social, environmental, and/or economic constraints on the client’s ability to follow-through successfully with an action plan.

32) Based on an initial action plan, take specific steps to initiate an admission or referral, and ensure follow-through.

33) Select and use comprehensive assessment instruments that are sensitive to age, gender and culture, and which address: (a) History of alcohol and other drug use (b) Health, mental health, and substance-related treatment history (c) History of sexual abuse or other physical, emotional, and verbal abuse, and/or other significant trauma (d) Family issues (e) Work history and career issues (f) Psychological, emotional, and world-view concerns (g) Physical and mental health status (h) Acculturation, assimilation, and cultural identification(s) (i) Education and basic life skills (j) Socio-economic characteristics, lifestyle, and current legal status (k) Use of community resources (l) Behavioral indicators of problems in the domains listed above.

58) Confirm the client’s eligibility for admission and continued readiness for treatment/change.

59) Complete necessary administrative procedures for admission to treatment.

111) Prepare accurate and concise screening, intake, and assessment reports.

PCN-610 Option 2: Case Study

David is a 49-year-old married man with two adult children. He has been married for 21 years. He has been employed as a metallurgical engineer in a local steel mill for 20 years. David noted he use to enjoyment going to work, but now, he states some days he would rather just stay home. David married his high school sweetheart. He describes their relationship as “typical.” They eat meals and attend family gatherings together but do little else as a couple. David use to spend his spare time reading, playing golf, and watching TV. For the last 6 months, David has felt blue and his appetite has decreased. He stated he doesn’t have any desire to do any of things he use to enjoy and would rather spend time alone in his bedroom. David complained of irritability and low energy. Within the last 2 months, David noted he has experienced more physical pain in his back and neck area. Because he has not been sleeping well, Robert drinks more at night. He stated that when he was younger, he use to drink more frequently but now he only drinks two or three beers per night. Sometimes, he feels like life is hardly worth living. Robert has tried to “snap himself” out of this sour mood, but nothing seems to work. David oldest son stated he is concerned his father may need to go see a doctor, because his father appears to be acting usual. David stated that his sister used to have similar problems. He is resistant to going to see a doctor and believes his mood will eventually improve.

David’s sister Lisa has struggled with depression for over 10 years. She is currently seeing a psychiatrist and a counselor. In the past, Lisa reported an increase in emotional and physical fatigue, low mood, increased weight gain, and disrupted sleep. Lisa has a negative outlook and states that when things are looking up, something always goes terribly wrong.

Psychosocial Assessment
____ Part 1 (Topic 2)

Template

____ Part 2 (Topic 3)

Name:
______________________________ Date: _________________ DOB: ________________

Age: ________________________________ Start Time: ____________ End Time: ___________

Identifying Information:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Presenting Problem:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Life Stressors:

Substance Use/Abuse: FORMCHECKBOX
Yes FORMCHECKBOX
No

Addictions (i.e., gambling, pornography, video gaming)

Medical/Mental Health Hx/Hospitalizations:

Abuse/Trauma:

Social Relationships:

Family Information:

Spiritual:

Suicidal:

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Homicidal:

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Assessment:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Initial Diagnosis (DSM):

________________________________________________________________________________________________________________________________________________________________________

Initial Treatment Goals:

Plan:

Name: _____________________________________________

Date: __________________

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