1
Biopsychosocial Assessment
By: Student name
Lehman College - City University Of New York Department of Social Work
Undergraduate Social Work Program
SWK 312-Social Work Practice II
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Biopsychosocial Assessment
I. Identifying Information
1. Name (initials): E.R.
2. Age, Sex, Gender identity: 13 years old, Male
3. Ethnic background/identification, race: African American
4. Marital/Relationship Status: Not Applicable
5. Appearance:
a. The client’s physical appearance (dressing): Well groomed, has clean fitted
clothes
b. Communication styles and abilities or deficits: Soft spoken, open but timid. He’s
social
c. Thought processes- Very intelligent, clearly self-aware, determined to work on
his coping abilities
d. Expressive overt behaviors -Respectful, experiences challenges with self-
expression.
e. Reports from professionals or family (medical, psychological, legal)- has IPE,
mandated to receive counseling services
f. Mental status exam (if appropriate)- Has irritability/temper issues, is cognizant
of triggers; strives to keep at bay. The problem persists and has escalated since
initial meeting
6. Current employment/educational status- Not employed, a middle school student
7. Household composition and circumstances (current living situation)-Lives with parents
and siblings, poor background, lives in poor neighborhood.
8. Immigration status-Not applicable, is a US citizen by birth
9. Preferred language of interventions-English
II. Presenting Problem/Reason for referral
This section identifies the referral source and gives a summary of the reason for the referral
according tothe referral source.
1. Referral source (include the circumstances of how the client came to the attention of the
referral source)
a. Includes the client’s description of the problem or services needed,
the duration of theproblem and its consequences for the client
The client was referred to the hospital by his school clinic and was accompanied by his mother.
The client was reported to demonstrate symptoms of deteriorating mental health. He
reports issues of anger and emotional control, primarily triggered by heated situations,
such as teasing and slight provocation, such as questioning. He reports to have been
struggling to develop feasible coping mechanism to no avail. The problem has persisted
for a period not below 3 months and has affected his educational performance, social life
and self-confidence.
b. Past intervention efforts by an agency or the individual and/or
family related to thepresenting problem should also be
summarized.
2
Biopsychosocial Assessment
By: Student name
Lehman College - City University Of New York Department of Social Work
Undergraduate Social Work Program
SWK 312-Social Work Practice II
1
, 2
Biopsychosocial Assessment
I. Identifying Information
1. Name (initials): E.R.
2. Age, Sex, Gender identity: 13 years old, Male
3. Ethnic background/identification, race: African American
4. Marital/Relationship Status: Not Applicable
5. Appearance:
a. The client’s physical appearance (dressing): Well groomed, has clean fitted
clothes
b. Communication styles and abilities or deficits: Soft spoken, open but timid. He’s
social
c. Thought processes- Very intelligent, clearly self-aware, determined to work on
his coping abilities
d. Expressive overt behaviors -Respectful, experiences challenges with self-
expression.
e. Reports from professionals or family (medical, psychological, legal)- has IPE,
mandated to receive counseling services
f. Mental status exam (if appropriate)- Has irritability/temper issues, is cognizant
of triggers; strives to keep at bay. The problem persists and has escalated since
initial meeting
6. Current employment/educational status- Not employed, a middle school student
7. Household composition and circumstances (current living situation)-Lives with parents
and siblings, poor background, lives in poor neighborhood.
8. Immigration status-Not applicable, is a US citizen by birth
9. Preferred language of interventions-English
II. Presenting Problem/Reason for referral
This section identifies the referral source and gives a summary of the reason for the referral
according tothe referral source.
1. Referral source (include the circumstances of how the client came to the attention of the
referral source)
a. Includes the client’s description of the problem or services needed,
the duration of theproblem and its consequences for the client
The client was referred to the hospital by his school clinic and was accompanied by his mother.
The client was reported to demonstrate symptoms of deteriorating mental health. He
reports issues of anger and emotional control, primarily triggered by heated situations,
such as teasing and slight provocation, such as questioning. He reports to have been
struggling to develop feasible coping mechanism to no avail. The problem has persisted
for a period not below 3 months and has affected his educational performance, social life
and self-confidence.
b. Past intervention efforts by an agency or the individual and/or
family related to thepresenting problem should also be
summarized.
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