Biopsychosocial Assessment Page 2
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10If any brothers or sisters are living outside the home, list their names and ages:
_____________________________________________________________________________________
_____________________________________________________________________________________
If any brothers / sisters are deceased, please give name and year: _______________________________
FAMILY INFORMATION:
Place of birth: ___________________________
Child’s Race:
African-American Caucasian Native American Hispanic Asian Latino Other
(specify) _____________________________________
Was the child adopted? Yes No If yes, at what age? _______ From where? __________________
Has the child ever been placed outside of the home? Yes No If yes, where? __________________
In how many residences has the child lived since birth? ________________________________________
Has the child been physically or sexually abused, assaulted or molested? Yes No Don’t know
If yes, specify by whom and when: _________________________________________________________
Have the child’s parents or any other family members had any mental health or emotional problems?
Yes No If yes, describe: ________________________________________________________________
PRESENTING PROBLEM:
Briefly describe your child’s current difficulties: _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How long has this problem been of concern to you? ___________________________________________
When was the problem first noticed? _______________________________________________________
What seems to help the problem? _________________________________________________________
What seems to make the problem worse? ___________________________________________________
Has the child received evaluation or treatment for the current problem or similar problems? Yes ___ No ___
If yes, when and with whom? _____________________________________________________________
Is the child on any medication at this time? Yes ____ No ____
If yes, please note kind of medication: ______________________________________________________
How do you want your child’s situation to be different after coming here? ___________________________
_____________________________________________________________________________________
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