Adult Biopsychosocial History

Adult Biopsychosocial History

Lisa Inoue LMSW PLLC
In preparation for our first appointment, please complete the following questions to the best of your ability. The information will help me to better understand your current life circumstances, your concerns, your strengths, and your goals for seeking psychotherapy. Feel free to leave blank any questions that are not relevant to you or that you would prefer not to answer with the exception of the questions related to past experiences with harm to self or others.
Identifying Information
Name*

First NameLast Name
Place of Birth*
Ethnicity
Gender Identification
Psychotherapy Goals
How did you become aware of my services, or who referred you?
What would you like to work on in psychotherapy?
How did you decide that now is a good time to begin psychotherapy?
What are your personal strengths and abilities?
What would you like to be different after completing psychotherapy?
Health and Wellness
Please discuss which wellness, lifestyle and/or self-care practices you engage in regularly.
Present State of General Health

ExcellentGoodFairPoor
Please describe your present sleeping pattern (e.g. hours per night; restful or not; problems getting to sleep or waking early).
Please describe your eating patterns (e.g. number of meals & snacks per day, restrictions).
Please state significant medical problems for which you have been or are being treated.
Please list approximate dates and nature of any surgical procedures.
If you have had any head injuries, please describe, including approximate date(s).
Please list any other accidents or serious injuries.
If you have any disabilities that require accommodation, please describe.
Please list any allergies and indicate whether they are mild, moderate, or severe.
Please list any non-psychiatric medications (prescription and over-the-counter) you are taking, including dose and frequency.
Please provide the approximate date of your last complete physical exam and the results.
Name of your present internist or physician:
How would you describe your sexual orientation?
How many biological children have you had?
Please describe the current state of your sexual health or functioning.
If you have ever experienced or been a partner to someone who has experienced pregnancy loss, please elaborate.
If you or a partner has ever experienced infertility or infertility treatment, please elaborate.
Please indicate the amount and frequency of use of the following.
Past Usage of Alcohol, Caffeine, Nicotine, Marijuana, or other Drugs
Present Usage of Alcohol, Caffeine, Nicotine, Marijuana, or other Drugs
Has anyone every expressed any concerns about your substance use? If so, who?
Has your substance use ever gotten in the way of work/family/social obligations?
Have you ever tried to cut down or stop your substance use? If so, what happened?
Have you ever received any treatment for substance abuse? If so, please describe (e.g. inpatient, outpatient, approximate dates, outcomes.)
Have you ever struggled with any other addictive behaviors (e.g. food, gambling, sex, video games, media/technology)? If so, please describe.
Mental Health
Have you worked with a psychotherapist in the past?

YesNo
If so please give the approximate dates, type (i.e. individual, couple, family) and duration of the therapy(ies).
What was most useful to you in this work?
What do you wish could have been different or more helpful?
Please list any psychiatric medications (i.e. to treat anxiety, depression, inattention, disturbing thoughts, etc.) you have taken or are taking. If more space is needed, please use side or back.
Name of current psychiatrist or prescribing physician:

First NameLast Name
Have you ever had a psychiatric hospitalization?

YesNo
If so, please describe including dates, reason, and outcome.
Have you ever made or threatened to carry out a suicide attempt?*

YesNo
If so, please give approximate date(s) and describe.*
Have you ever harmed or threatened to harm another person?*

YesNo
If so, please give approximate dates(s) and describe.*
Please indicate relatives with a history of emotional or mental disorder or suicide. If known, please include diagnosis and treatment.
Please note relatives with a history of alcoholism, substance abuse or excessive alcohol use.
Have you ever experienced abuse or harassment?

YesNo
If so, please describe (e.g. physical, sexual, emotional), including when and by whom.
Have you ever had an experience that was life-threatening, overwhelming in emotional intensity or otherwise troubling in some way? If so, please describe.
Relationships and Current Family

If applicable, please give the approximate date your present partner relationship began. If applicable, please provide information about your partner and/or children.
* E = Excellent, G = Good, F = Fair, P = Poor
If you have a current relationship with a significant other or partner, please describe your experience of the relationship and any concerns that you have with this present relationship.
Please list any previous marriages or long-term relationships, including first name, year relationship began, year ended, and any children from this relationship.
If you are a parent, please describe your relationship with your children.
What has been most satisfying to you as a parent?
What has been most challenging to you as a parent?
Relationship with Self and Others (Besides Partner)
To whom, if anyone, do you typically turn for emotional support?
Briefly describe the nature and quality of your closest friendship(s).
Please describe any concerns you have about your friendships or friendship patterns.
Education
Please state your highest level of education, including discipline and degree.
Work
How long have you worked at your present job?
What are your specific work responsibilities?
How satisfied are you with your present job?
What aspects of your present job do you enjoy the most?
How are your relationships with your peers and supervisors at work?
Please list other significant jobs you have had along with approximate dates.
Please describe any significant problems in past/present job situations.
Spirituality/Religion
If applicable, describe the role spirituality/religion has played in your life.
Legal
Have you had any past litigation or legal problems?

YesNo
If so, please explain.
Other
Is there anything else you would like me to know about you?
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Adult Biopsychosocial History

Identifying Information

Psychotherapy Goals

Health and Wellness

Mental Health

Relationships and Current Family

Relationship with Self and Others (Besides Partner)

Education

Work

Spirituality/Religion

Legal

Other