What Is A Biopsychosocial Assessment Template?
A Biopsychosocial assessment is a tool for gathering information on your client upon their intake into your practice. This assessment gathers information in three key areas, namely, biological; including medical information, medication history, drug interactions, and psychological; including past treatment, mental health, relationships, and social; developmental history, peers, and socioeconomic situation. With so many different factors to take into account in the Biopsychosocial Assessment, it’s a good thing we’ve created a to help you capture all of this information reliably and consistently with every client you see.
What is included in a Biopsychosocial Assessment?
A biopsychosocial assessment commonly includes 3 factors.
Firstly, biological factors. This considers information about the client pertaining to their physical health, such as their genes, age, infections, diet, hormones, and sleep as well as exercise habits. They can help you better understand client medical issues as well as their history.
The system also includes psychological factors that pertain to a person's thought processes. To understand your clients mental health and their state of mind, this will address areas of personality, stress, coping skills, disorders, as well as psychological traumas.
Finally, the assessment also touches on social factors, that affect thoughts and behaviours from social determinants and context. Emotional support can be a protective factor for mental health disorders, and so it is important to consider this dimension. And this section, you may explore family relationships, living situation, religion, hobbies, sexual and legal history, educational background, employment status, and more.
The 4 P’s of Biopsychosocial Assessment
This assessment also touches on the 4 P’s, which include predisposing, precipitating, perpetuating, and protective factors. This is a very common framework used within academic research and real practice.
This Biopsychosocial Assessment Template is in the form of a self-reported questionnaire which you can provide to your clients in order for them to complete themselves prior to their first session with you.
How To Use This Template For Biopsychosocial Assessment
Just follow these simple steps to start taking Biopsychosocial Assessments for your own clients.
Step 1. Download the PDF
The first step to incorporating this Biopsychosocial Assessment Template into your clinical practice is to download the assessment template, which you can access in PDF form using the link on this page.
Step 2. Provide the Template to your Client
This assessment is designed to be completed by your client in their own words, so you should simply provide the template to your client, ideally before their first session with you as part of their intake information.
Step 3. Assess Completed Template
Once your client has returned the completed template to you, ensure you read over it carefully using your clinical judgment and the principles of the Biopsychosocial model to determine relevant points to your patient’s presenting issue.
Step 4. Store the Assessment Securely
You may need to refer back to this information throughout your client’s treatment as you work together on a formulation for their presenting issues. As such, ensure this Biopsychosocial Assessment template is stored accessibly, but securely, as it contains highly sensitive and confidential patient information.
Biopsychosocial Assessment Example (Sample)
To see what sort of answers you could expect from this Biopsychosocial Assessment Template, just take a look at our example template below. This example documents the responses of a fictional client upon intake to illustrate how this assessment template works. While your clients will each have very different responses, it can still be useful to see a completed version of a template before implementing it in your own practice.
Who Can Use this Printable Biopsychosocial Assessment Template (PDF)?
This template is designed for mental health practitioners who routinely see clients for mental health, psychological, or psychiatric issues. This template is designed to be broad enough to serve clients from a range of different social, medical, psychological, and socioeconomic backgrounds, and a few of the professions that may find this template useful are listed here.
- Clinical psychologist
- Mental health nurse
- Family doctor/physician
While this template gathers medical information such as medication and medical history, it is not limited to use by physicians (psychiatrists, doctors etc.) as this information can be relevant for all practitioners, including non-physician specialties such as psychotherapists or counselors.
Why Is This Form Useful For Therapists?
Includes goal setting
This assessment includes a goal-setting question for your client, which can help you guide how you structure your sessions together. Additionally, these initial goals can be great to reflect on and see how they change over time.
Many of the questions in this assessment are phrased in an open-ended style, allowing your client to provide their answer in their own words without being restricted to one of a few items on a checklist.
Risk screening questions
This form includes some common risk-screening questions regarding pregnancy, HIV risk, and suicidal thoughts. Including these questions upon intake means one more layer of safety in terms of risk screening.
Benefits of Biopsychosocial Assessment Template
Keep your patient information organized
Using a structured, pre-formatted template allows you to keep all the information gathered in this Biopsychosocial Assessment well organized. This will ultimately help you, and others in your client’s care team, when you need to refer back to this information- ensuring you can find what you need in a timely manner.
This assessment can be completed entirely digitally, which has huge benefits for time-saving, information security, and the environment! Your client can fill the PDF using the interactive textboxes and checkboxes provided.
Standardize Biopsychosocial Assessment Process
Having the same template for every client’s Biopsychosocial Assessment ensures you are giving the same level of attention to every client upon intake, ultimately helping you standardize your procedures across your practice.
Another benefit of using this digital template is it allows for easy collaboration with others in your patient’s care team who may be providing concurrent treatment. This PDF is easily shareable, accessible, and readable for other practitioners, improving the coordination of your patient’s care.
Provide legal evidence
Finally, this assessment template provides solid evidence of your clinical procedures in the event of a legal situation or if you are required to provide evidence of the information gathered from your patient.
Why Use Carepatron For Biopsychosocial Assessment Software?
Your patient’s biopsychosocial assessment form contains confidential and sensitive information which you have a legal obligation to keep secure. While this may sound like a lot of administrative work, Carepatron makes it incredibly simple to store, access, share, and edit all different medical records, including this biopsychosocial assessment form, in a HIPAA-compliant way.
With your data privacy handled, you can then start to look for ways to improve your practice’s administration and management, and Carepatron has you covered there too. You can send out automated SMS or email appointment reminders and reduce no-show appointments, sync your team’s calendars, improve your organization, manage billing and medical coding, utilize our AI-powered voice-to-text dictation software, or offer your patients their own Carepatron client portal to schedule appointments with you and access their medical records securely.
Carepatron has a whole suite of software solutions to save you time so you can get back to doing what you do best, and you can even find this Biopsychosocial assessment template, and hundreds of other handy, premade templates, right from within Carepatron’s comprehensive, community template library.