Biopsychosocial Assessment Interview Assignment (Worth 100 points)                       
I want you to get the feeling for what is like to conduct a clinical interview (also called Intake Interviews/ Psychosocial Intake Interviews, Biopsychosocial Intake Interviews, etc).  Select a person that is willing to trust you with some personal information in a confidential manner and interview them with the questions below.  Please do NOT reveal the true name or identifying information on the individual.  You will use fictitious information in this area of the assessment.  Please instruct your volunteer to NOT reveal embarrassing or highly personal information. They are free to “make up information” during more sensitive sections of the interview. 
Adult Intake Assessment

Patient General Information

Name:
Mailing Address:
Phone Number(s):
Email address (if applicable):
Birth Date: Age:
Religion/Spirituality (indicate Denomination or Tradition):
Cultural/Ethnic Background:
Marital Status:
Gender/Sex:

Presenting Problem

1.  Provide a brief summary of the main problem(s):

2.  When did this start? How long has it been going on?

3.  Events that led to your seeking help:

4.  Describe any recent life changes or stressors:

5.  Who decided that you should come for help (e.g., you, a loved one, etc.)?

Your Developmental History

1.  To your knowledge, was your mother’s pregnancy “typical” (e.g., full-term)? If not, please explain:

2.  To your knowledge, did you achieve developmental milestones as expected (e.g., talking, walking, around same time as your peers)? If not, please explain:

Your Medical History

1.  Please list any current medical conditions:

2.  Please list ALL medications you are taking now, the dosages, and the reasons that you are taking them

3.  Please list any current supplements, vitamins, or herbs you are taking:

4.  Please describe any history of surgeries:

5.  Please describe any history of hospitalizations:

6.  Please describe any history of head injuries:

7.  Please describe any medical allergies or drug intolerances:

8.  Present height: Present weight:

9.  Please describe your sleep patterns. Include any difficulties such as sleepwalking, insomnia, recurrent dreams or nightmares:

10. Please describe your use of alcohol or any other drugs/substances:

Substance    How much?   How often?  Age when first used?   When did you last used/use?

a.

b.

c.

11.  Have you ever been in treatment for substance abuse or dependence? Please describe:

12.  Do you have any history of compulsive behaviors, such as sexual addiction, gambling, shopping, exercise addiction, or over-eating? If so, please describe:

Your Educational History

1.  Highest year reached in school (Jr/High School, College, Vocational School, etc):

2.   Average grades at last school:

3.  Specific learning disabilities (if any):

4.  Describe any suspensions, expulsions, or other problems in school:

5.  Did you enjoy school? Why or why not?

6.  What were your best subjects?

Employment History

1.  Current Occupation:

2.  Describe the types of jobs you have had and the number of years spent at those jobs:

3.  What has been your favorite occupation? Your least favorite?

4.  Explain any work-related problems:

5.  What would your employers or supervisors say about you?

6.  Describe any military history:

7.  If employed, are you happy with your current position?

Your Legal History

1.  Please list any convictions:

2.  Please list any incarcerations:

3.  Have you ever been involved in any legal action or court case?  Yes/No  If yes, please explain:

Religious/Spiritual History

1.  How important is organized religion in your life?

2.  Do you consider yourself to be spiritual?

3.  Describe your religion/spirituality. Include your denomination or tradition if applicable:

4.  How long have you been following this path?

5.  Describe your level of satisfaction with your current religious/spiritual path:

Your Social History

1.  To whom were you closest as a child?

2.  Describe any mentors you had as a child (e.g., parent, teacher, coach, friend’s parent, etc.):

3.  What is/was your father’s occupation?

4.  How would you describe your relationship with him?

5.  What is/was your mother’s occupation? How

6.  How would you describe your relationship with her?

7.  If you have any siblings, please describe your current relationship with them here:

8.  Were you shy or outgoing as a child? How are you as an adult?

9.  Please describe your current friendships (anything you want to say here is fine):

10.  Are you happy with the quality of your friendships? 

11.  Are you happy with the size of your current network of friends and acquaintances? 

12.  How do you typically meet your friends?

13.  Are you currently married or in a romantic or committed relationship?  If so, how long have you been in this relationship?

14.  How would you describe your relationship?

15.  On a scale of 1-10 (with 1 being the least satisfied and 10 being the most satisfied), how would you rate the quality of your relationship?

16.  Please list previous significant relationships and durations:

17.  How do you typically meet your romantic partners?

18.  If a parent, please list names and ages of children:

19.  Are you divorced?       If yes, do you have custody of your children? 

20.  Please describe your current relationship with your children.

Your Sexual History

Please answer only as much as you feel comfortable:

1.  Age at first sexual experience:

2.  Number of sexual partners in your lifetime:

3.  Do you have any history of past or current sexual dysfunction? If so, please describe:

4.  If you are currently involved in a sexual relationship, describe your level of satisfaction with your sexual experiences:

5.  Describe any history with infertility and/or miscarriages:

6.  Describe any history with STDs:

7.  Any history of abortion?

8.  Any history of sexual abuse, molestation or rape?

9.  Have you ever had any concerns about your sexual orientation? If so, please describe:

10.  Please circle where you fall on the Kinsey Scale:

0 = exclusively heterosexual
1 = predominantly heterosexual, incidentally
2 = predominantly heterosexual, but more than incidentally homosexual
3 = equally heterosexual and homosexual
4 = predominantly homosexual, but more than incidentally heterosexual
5 = predominantly homosexual, incidentally heterosexual
6 = exclusively homosexual

Your Family Mental Health History

Has anyone in your family (either immediate family members or relatives) experienced difficulties or been diagnosed with any of the following? (circle any that apply and list family member, e.g., Sibling, Parent, Uncle, etc.):

Difficulty:							Relationship:

Depression 

Bipolar Disorder 

Anxiety Disorders 

Panic Attacks 

Schizophrenia Alcohol/Substance Abuse 

Eating Disorders Learning Disabilities 

Trauma History 

Suicide Attempts 

Your Mental Health History

1.  If you’ve ever been to counseling or therapy before, please describe below:
When? How Long? For What Reason? (please circle)

2. Describe your satisfaction with therapy

3.  Have You Ever Experienced:

Extreme depressed mood 

Wild Mood Swings 

Rapid Speech 

Extreme Anxiety 

Panic Attacks 

Phobias 

Sleep Disturbances 

Hallucinations 

Unexplained losses of time 

Unexplained memory lapses 

Alcohol/Substance Abuse 

Frequent Body Complaints 

Eating Disorder 

Body Image Problems 

Repetitive Thoughts (e.g., Obsessions) 

Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing) 

Homicidal Thoughts 

Suicide Attempt(s)