CLINTON COUNSELING CENTER – ADULT BIOPSYCHOSOCIAL ASSESSMENT

DEMOGRAPHICS
Legal Name:
Age: Date of Birth: Social Security #:
Race: □ Caucasian □ Black □ Hispanic □ Native American □ Other:
Current Address: Current Phone:
Street: Home:
City/State: Cell:
Zip:
Emergency Contact: Phone:
□ Guardian □ Representative payee □ Personal representative
Name: _____________________________________ Phone: ________________________________
Insurance Information: □ Medicaid □ Medicare □ Blue Cross/Blue Shield □ MiChild
□ Value Options □ Cigna □ United Behavioral Healthcare □ Aetna
□ Adult Benefit Waiver □ Medicaid Spend down □ Other _______________________________
□ No Insurance Benefits – current household income: _______________________________________
SUBSTANCE USE HISTORY:
Consequences as a result of Drug/Alcohol Use (select all that apply)
□ Hangovers □ Seizures □ Sleep Problems □ Drinking & Driving
□ Overdoses □ Liver Disease □ Lost Job □ Stealing for drugs
□ Binges □ GI Bleeding □ Left School □ Arrest
□ Blackouts □ Increased tolerance □ Relationship Losses □ Jail
□ DTs/Shakes (need more to get high) □ Traded sex for drugs □ Other:
Risk Taking/Impulsive Behaviors (current or past) – select all that apply
□ Gambling □ Gang involvement □ Selling drugs □ Reckless driving
□ Unprotected sex □ Shoplifting □ Carry/using weapons □ Other _____________
Client’s thoughts about making changes to substance use:
□ Not ready to quit □ Making plans to quit □ Quit and need help to prevent a
□ Thinking about quitting □ Already started making changes relapse

History of Substance Abuse Treatment: □ No previous treatment

Name of Treatment Program Type of Date of Treatment Status
Treatment
□ Inpatient □ Completed
□ IOP □ Dropped Out
□ Outpatient □ Other:
□ Inpatient □ Completed
□ IOP □ Dropped Out
□ Outpatient □ Other:
□ Inpatient □ Completed
□ IOP □ Dropped Out
□ Outpatient □ Other:
□ Inpatient □ Completed
□ IOP □ Dropped Out
□ Outpatient □ Other:
□ Inpatient □ Completed
□ IOP □ Dropped Out
□ Outpatient □ Other:

Clinical Impression: (Staff use only):

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PSYCHOLOGICAL/EMOTIONAL:
Check all current symptoms:
□ Depressed mood □ No motivation □ Sleep problems □ Hallucinations
□ Frequent crying spells □ No interest in activities □ Manic episode □ Paranoia
□ No energy □ Changes in weight □ Panic attacks □ Thoughts of death
□ Irritable often □ Feeling worthless □ Constant worry □ Obsessions
□ Problems concentrating □ Hopelessness □ Anxiety □ Hyperactivity
History of Suicide Attempts □ No □ Yes When:________________________ How: __________________
History of Hurting Others □ No □ Yes When: _______________________ How: __________________
Past/Current Mental Health Diagnosis: __________________________________________________________
Current Mental Health Medications: ____________________________________________________________
Doctor prescribing medications? Name: ________________________________ Phone: __________________
Address: __________________________________________________________________________________
Past Mental Health Medications: _______________________________________________________________
Family history of mental health disorders:
Family Member Diagnosis

History of Mental Health Treatment: □ No previous treatment

Name of Treatment Program Type of Date of Treatment Status
Treatment
□ Hospital □ Completed
□ Partial Day □ Dropped Out
□ Outpatient □ Other:
□ Hospital □ Completed
□ Partial Day □ Dropped Out
□ Outpatient □ Other:
□ Hospital □ Completed
□ Partial Day □ Dropped Out
□ Outpatient □ Other:
□ Hospital □ Completed
□ Partial Day □ Dropped Out
□ Outpatient □ Other:
□ Hospital □ Completed
□ Partial Day □ Dropped Out
□ Outpatient □ Other:

Clinical Impression: (Staff use only):

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MEDICAL:
Medical Condition(s): Medication(s) Dose

Allergic to any medications? □ No □ Yes What medication(s)? ____________________________

Primary Care Physician’s Name: Address: Phone:

□ No primary care physician

Detoxification History: Substance(s): __________________________________________ □ Never detoxed
Symptoms: □ DTs/Shakes □ Vomiting □ Diarrhea □ Seizures □ Achy □ Sleeplessness
□ No appetite □ Anxiety □ Hallucinations □ Other: _______________________________
Current Sleep: □ No sleep problems □ Can’t fall asleep □ Waking often in the night
□ Sleep more than 9 hours per night □ Sleep less than 6 hours per night
Current Exercise: □ None □ Exercise 1-3x/month □ Exercise 1-3x/week □ Exercise daily
Current Diet: □ Healthy eating □ Overeating □ Eating mostly junk food
□ Bulimia (eating too much and vomiting) □ Anorexia (not eating enough)
Current appetite: □ Good □ Fair □ Poor

Clinical Impressions: (Staff use only):

FAMILY OF ORIGIN: (What happened while growing up – check all that apply)
Who raised client? □ Mother □ Father □ Grandparent □ Other: ______________________________
Substance use in the family? □ No □ Yes Who? __________________________________
Client was disciplined by: □ Not disciplined □ Spanked/hit □ Yelled at □ Time out/grounding
Verbal Abuse? □ No □ Yes Age of abuse ________By Whom? ___________________
Physical Abuse? □ No □ Yes Age of abuse ________By Whom? ___________________
Neglect? □ No □ Yes Age of abuse ________By Whom? ___________________
Impression of upbringing: □ Healthy □ Fair □ Dysfunctional

Clinical Impressions: (Staff use only):

ETHINIC/CULTURAL/SPIRITUAL BACKGROUND:
What cultural group do you identify with the most (check all that apply):
□ Caucasian (White) □ African American (Black) □ Latino
□ Asian □ Hispanic □ Native American
□ Other: __________________
What religious group do you identify with the most (check all that apply):
□ None □ Baptist □ Lutheran □ Protestant □ Jewish
□ Catholic □ Muslim □ Non-denominational □ Jehovah Witness □ Other: _______________
What are your spiritual beliefs?
□ Believe in Higher Power □ Uses prayer □ Seeking connection with others
□ Seeking harmony □ Believe in Karma □ Want to strengthen spirituality

Clinical Impressions: (Staff use only):

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SEXUALITY:
Check all that apply:
Sexual Orientation: □ Heterosexual (like opposite sex) □ Homosexual/Gay/Lesbian
□ Bisexual (like both sexes) □ Transgender
□ Comfortable with sexual orientation □ Concerns with sexual orientation
Sexual abuse: □ Have been sexually abused Age of abuse:________ By whom: _______________________
□ Have sexually abused others
□ No history of sexual abuse
□ Sexual abuse history is a current area of concern

Clinical Impressions: (Staff use only):

CURRENT FAMILY RELATIONSHIPS:

Marital Status: □ Never Married □ Married □ Separated □ Divorced □ Widowed
□ Living with partner □ In relationship
Children: □ None
Name Age Gender Client has Child lives Additional information
custody? with?
□ M □ F □ Yes □ No
□ M □ F □ Yes □ No
□ M □ F □ Yes □ No
□ M □ F □ Yes □ No
Has client ever had involvement with Child Protective Services? □ No □ Yes Year: ________________
Check all that apply:
Deceased Regular Infrequent/ Supports Does not Used Conflict in
contact No contact recovery understand substances relationship
recovery with
Spouse/Partner
Mother
Father
Sibling: __________
Sibling: __________
Sibling: __________
Child: ___________
Child:____________

Identify family that would be willing to participate in treatment to assist client in recovery: ________________

Clinical Impression: (Staff use only):

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CURRENT SOCIAL SUPPORTS:
Check all that apply:
□ No current social support □ Isolating □ Have a current sponsor
□ Friends that use substances □ Anxiety makes it hard to meet people □ Friends that support recovery
AA/NA Meetings (check all that apply):
□ Never attended any meetings □ Don’t like meetings □ Attend meetings 1-3x/month
□ Attended meeting in the past □ Find meetings helpful □ Attend meetings 1-3x/week
□ Currently attending meetings □ Need to go to meetings again □ Attend meetings daily

Clinical Impression: (Staff use only):

CURRENT LEISURE/RECREATION/TIME MANAGEMENT:

Check all that apply: □ Do not participate in any activities
Activity Past Present Substance use involved with
activity activity this activity
Time with friends
Time with family
Classes/School
Work
Hobby: _________________________________________
Watch television/Play video games
Clubs/Bars
Casinos
Participate in sports/exercise
Other: __________________________________________

Clinical Impression: (Staff use only):

EDUCATIONAL:
Check all that apply:
Education: □ High School Graduate or GED □ Less than 12 years of school: Last grade completed: ______
□ College: # of years _____ □ Vocational Schooling: # of years ______
Current Schooling: □ No □ Yes
Do you need help with reading and/or writing? □ No □ Yes
Any learning disabilities or other educational or learning problems? □ No □ Yes: ___________________
How do you learn the best? □ Reading □ Writing □ Listening to information □ Practicing

Clinical Impression: (Staff use only):

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EMPLOYMENT/VOCATIONAL:
□ EMPLOYED □ Full-time □ Part-time □ Contractual/Side Jobs
Employer: _________________________________________________ Length of Employment: __________
Job Description: ___________________________________________________________________________
Check all that apply: □ Satisfied □ Not satisfied □ Conflict with supervisor □ Conflict with coworkers
□ I have used substances at work □ Others use substances at work
□ Employment will help with recovery □ Employment could hurt recovery
Explanation: ____________________________________________________________
□ UNEMPLOYED Last employer: ___________________________________________________________
Reason for leaving: _______________________________________________________
□ Currently looking for work □ Disabled □ Need job skills training □ Currently in school
□ Never been employed □ Homemaker □ Unstable work history □ History of Military service
□ Not looking for work due to: ________________________________________________________________

Clinical Impression: (Staff use only):

LEGAL:
Current Legal Status: □ None □ Probation □ Parole □ Awaiting Sentencing □ Awaiting Trial
History of Legal Charges:
Charge (most recent first) Year Arrested for Outcome
Charge

Clinical Impression: (Staff use only):

FINANCIAL STATUS:
Check all that apply:
Finances are: □ Stable □ Struggling to pay bills □ Need assistance with basic needs
Need help with: □ Nothing □ Rent/Mortgage □ Food □ Utilities (electric, gas, water)
□ Healthcare □ Transportation □ Other: __________________________
Money management: □ Able to budget □ Gambling problems □ Compulsive spending □ Hoarding money

Clinical Impression: (Staff use only):

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FUNCTIONAL ASSESSMENT:
Client able to care for self? □ Yes □ No – Explain:
Living Situation: □ Housing adequate □ Housing overcrowded □ Housing dangerous
□ Doubled up – living in someone else’s house □ Transitional or ¾ housing
□ Homeless □ Temporary Shelter □ At risk of homelessness
Assistive/Adaptive Needs: □ Glasses/Contacts □ Braille □ Cane
□ None □ Hearing Aids □ Reads lips □ Needs sign language
□ Walker □ Crutches □ Wheelchair
□ Translated verbal information – Language: _____________________________
□ Translated written information – Language: _____________________________

SNAP (Strengths, Needs, Abilities and Preferences)

Strengths: □ Family support □ Desire for help □ Social support □ Financial stability □ Spiritual
□ Resilient □ Stable relationship □ Stable housing □ Other: _______________________
Needs: □ Coping skills □ Relapse prevention skills □ Support for recovery □ Medications
□ Transportation □ Financial help □ Other: _______________________________________
Abilities: □ Insightful □ Good communication skills □ Good writing skills
□ Other: ________________________________________________________________________
Preferences: □ Appointment times – Needs: _____________________________ □ Therapist in Recovery
□ Male Therapist □ Female Therapist □ Group therapy □ Individual therapy
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