CNL-605: Biopsychosocial Assessment Template
Client’s Name: Enter client’s name here.
Date: Select or enter the date here.
DOB: Select or enter the client’s DOB here.
Age: Enter the client’s age here.
Start Time: Enter the start time here.
End Time: Enter the end time here.
Identifying Information:
[Enter client’s identifying information here.]
Presenting Problem/Chief Complaint:
[Enter client’s presenting problem/chief complaint here.]
Substance Use History:
[Enter client’s substance use history here.]
Addictions (i.e., gambling, pornography, video gaming):
[Enter client’s addictions here.]
Medical History/Mental Health History/Hospitalizations:
[Enter client’s medical history, mental health history, and/or hospitalizations here.]
Abuse/Trauma History:
[Enter client’s abuse/trauma history here.]
Social History and Resources:
[Enter client’s social history and resources here.]
Legal History:
[Enter client’s legal history here.]
Educational History:
[Enter client’s identifying information here.]
Family History:
[Enter client’s family history here.]
Cultural Factors:
[Enter client’s cultural factors here.]
Resources, Strengths, and Weaknesses:
[Enter client’s resources, strengths, and weaknesses here.]
Case Conceptualization (Conceptualize the case using your preferred theoretical orientation):
[Enter your case conceptualization here.]
Clinical Justification:
[Enter your clinical justification here.]
Initial Diagnosis (DSM-5):
Principal Diagnosis:
ICD-10 Code:
DSM-5 Disorder:
Subtypes:
Specifiers:
Provisional Diagnosis:
ICD-10 Code:
DSM-5 Disorder:
Subtypes:
Specifiers:
Initial Treatment Goals Informed by Theoretical Orientation (SMART Goal Format):
Goal # 1:
Objectives:
Interventions:
Target Date:
1.
2.
Goal # 2:
Objectives:
Interventions:
Target Date:
1.
2.
Student Clinician’s Name: Enter your name here.
Date: Select or enter the date here.
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