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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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