1
E. R’s Biopsychosocial Assessment
By (Student name)
Institutional Affiliation (School)
Course Title (Class)
Instructor (Tutor)
Date
, 2
E. R’s Biopsychosocial Assessment
I. Identifying Information
1. Name (pseudonym/initials): E.R
2. Age & Sex: Male, 13 years of age
3. Ethnicity, race: African American descent
4. Marital Status: Not Applicable
5. Appearance:
E.R poses a positive first impression. He is well groomed and comes donned in clean,
well-fitting attire. He is well kept and looks pleasantly decent. In terms of communication, E.R is
soft spoken, He appears social as observed through his expressive abilities (open communication)
during sessions. He’s however, demonstrates timidity. He has a positive thought process. He
demonstrates tremendous intelligence and intrinsic self-determination to work on his coping
abilities. He expresses a good scope of self-awareness, e.g. acknowledgement of being unwell,
potential triggers of his problems (e.g. etiologies of his temper/irritability) and need to build
coping mechanisms during heated situations. In terms of expressive overt behaviors, E.R
demonstrates a respectful personality. He however, experiences challenges with self-expression.
Results of mental status exam reveal a diagnosis of irritability/temper management issues which is
worsening. Due to his condition, E.R has been mandated to receive counselling services. He
strives to keep his temper issue at bay, but the problem has somewhat escalated since the last
meeting
6. Current employment-Not Applicable, too young
7. Educational status- Middle school student
8. Household composition and circumstances -Lives with parents and a sibling. The family lives in a
poor neighborhood/community.
9. Immigration status-Not an immigrant, is a U.S. citizen by virtue of being born in the country
10. Preferred language of interventions-English
II. Presenting Problem/Reason for referral
E. R’s Biopsychosocial Assessment
By (Student name)
Institutional Affiliation (School)
Course Title (Class)
Instructor (Tutor)
Date
, 2
E. R’s Biopsychosocial Assessment
I. Identifying Information
1. Name (pseudonym/initials): E.R
2. Age & Sex: Male, 13 years of age
3. Ethnicity, race: African American descent
4. Marital Status: Not Applicable
5. Appearance:
E.R poses a positive first impression. He is well groomed and comes donned in clean,
well-fitting attire. He is well kept and looks pleasantly decent. In terms of communication, E.R is
soft spoken, He appears social as observed through his expressive abilities (open communication)
during sessions. He’s however, demonstrates timidity. He has a positive thought process. He
demonstrates tremendous intelligence and intrinsic self-determination to work on his coping
abilities. He expresses a good scope of self-awareness, e.g. acknowledgement of being unwell,
potential triggers of his problems (e.g. etiologies of his temper/irritability) and need to build
coping mechanisms during heated situations. In terms of expressive overt behaviors, E.R
demonstrates a respectful personality. He however, experiences challenges with self-expression.
Results of mental status exam reveal a diagnosis of irritability/temper management issues which is
worsening. Due to his condition, E.R has been mandated to receive counselling services. He
strives to keep his temper issue at bay, but the problem has somewhat escalated since the last
meeting
6. Current employment-Not Applicable, too young
7. Educational status- Middle school student
8. Household composition and circumstances -Lives with parents and a sibling. The family lives in a
poor neighborhood/community.
9. Immigration status-Not an immigrant, is a U.S. citizen by virtue of being born in the country
10. Preferred language of interventions-English
II. Presenting Problem/Reason for referral
