Writing an Effective Biopsychosocial Assessment Template PDF

Creating an Effective Biopsychosocial Assessment Template [Editable PDF]

Properly diagnosing and effectively treating clients is the goal of every mental health professional. A biopsychosocial assessment helps counselors, social workers, and behavioral health professionals learn about their clients on multiple levels and also helps them understand their clients subjective viewpoints. To make the best possible diagnosis, it’s important that your biopsychosocial assessment template asks the right questions. In this post, we will dissect what makes an effective biopsychosocial assessment and we’ll also answer some questions around this topic.

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What is a Biopsychosocial Assessment?

Biopsychosocial assessments are a product of the biopsychosocial model proposed by Dr. George Engel in 1977. Dr. Engel proposed that a person’s well-being is influenced by biological, psychological, and social factors. In layman’s terms, the body and mind are not separate entities. For example, if a person break’s their leg and also receives no social support, they can become sad or depressed. Reversely, a person who is depressed by neglect relationships and self-care resulting in physical and social difficulties. Many mental health professionals widely view clients holistically and take into account how one afflicted area in a person’s life can affect another area of their life.

The biopsychosocial model views health and illness as the result of 3 main contributing factors including biological characteristics (genes), behavioral factors (lifestyle choices, health practices, stress levels), and social conditions (family, relationships, social support, cultural influence, spiritual influence, etc.). Combining these three contributing factors, mental health professionals

According to Marquette University, a biopsychosocial (BPS) assessment is:

an approach that emphasizes the importance of a systemic view of the individual and an integration of biological, psychological, and sociocultural factors on human development and functioning. A BPS approach has been illustrated to be useful in the treatment of a number of disorders including depression, anxiety, addictions, as well as various chronic medical disorders.

As mentioned above, a biopsychosocial assessment is used to effectively treatment a number of mental health issues. A well-written biopsychosocial assessment template helps practitioners greatly in their mission of providing proper treatment.



What is the Purpose of a Biopsychosocial Assessment?

A biopsychosocial assessment helps counselors, psychologists, social workers, therapists, psychiatrists, and other mental health professionals learn about their clients on a number of levels early on in the treatment process while also learning about their subjective viewpoints on a number of different topics, resulting in a more proper diagnosis and effective treatment plan.

What Should Be Included in a Biopsychosocial Assessment?

biopsychosocial assessment template what to include

Mental health professionals typically ask their clients to fill out a biopsychosocial assessment early on in treatment as part of an initial assessment. As the name suggests, there are three main parts in a biopsychosocial assessment template, including:

1. Biological Factors

According to the Psychology Dictionary, biological factors include “Anything which affects the function and behavior of a living organism. Internally, this factor can be a physical, physiological, chemical, neurological, or genetic condition which causes a psychological effect.” Research at NIMH shows that many mental disorders are caused by combined factors of biological, environmental, psychological, and genetic.

Because your genes can play a massive role in your mental health, you may want to ask the questions pertaining to theses biological factors:

  • Age
  • Genes
  • Immune Response
  • Hormones
  • Sleep Habits
  • Exercise
  • Appetite and Eating Patterns
  • Diet
  • Infections
  • Allergies
  • Physical Ailments

It’s important to ask the right biological questions to help you understand a client’s medical issues and history that can influence other areas of their life. Your biopsychosocial assessment template should include questions about personal medical, family medical history and mental health history, substance use history, sleeping patterns, diet, and exercise habits.

Questions to Include to Assess Biological Factors

Here are some questions we ask in our biopsychosocial assessment template:

  • Please list all of your allergies to foods or medications
  • Are you pregnant now?
  • Who is your primary care physician?
  • Current APRN/Psychiatrist (if applicable)
  • Current and Past Medical/Surgical Problems
  • Past and Current Medications and Dosages
  • Are you experiencing any medical problems now? Please explain
  • Is there a family history of addiction?
  • Does anyone in your family have a history of mental health disorders? Please explain

2. Psychological Factors

The APA describes psychological factors as “functional factors—as opposed to biological (constitutional, hereditary) factors—that contribute to the development of personality, the maintenance of health and well-being, and the etiology of mental and behavioral disorder.” Psychological factors can play a big role in a person’s mental health. A person’s psychological factors can directly impact a person’s physical well-being, as demonstrated by a study published in Neural Plasticity: Up to 85% of patients with chronic pain experience severe depression.

To understand clients better, you can ask questions pertaining to the following psychological factors:

  • Stress
  • Personality
  • Psychological traumas
  • Coping skills
  • Suicidal ideation and self-harm
  • History of care
  • Aspirations
  • Reasons for seeking treatment

Questions to Include to Assess Psychological Factors

In the psychological piece of the biopsychosocial assessment, you should aim to grasp a person’s thoughts, how they’re feeling, behaviors, their aspirations, and get an overall idea about their mental state. Below are a few questions we included in our biopsychosocial assessment template pertaining to psychological factors:

  • Please describe what brings you in today?
  • How long have you been experiencing this problem?
  • Rate the intensity of this problem (1 to 5)
  • How is this problem interfering with your daily functioning?
  • What are your current goals for therapy / treatment?
  • If treatment is successful, how would your life be different?
  • Are you currently experiencing any of the following symptoms now or in the last 30 days (please check all that apply)
  • Do you now or have you ever contemplated committing suicide?
  • Are you a survivor of trauma?

Getting answers to these questions will help you understand psychological factors that may be influencing your clients’ conditions.



3. Social Factors

The Psychology Dictionary defines social factors as “factors that affect our thought and behaviour in social situations. This includes feedback, splitting into smaller groups and unresolved conflict. Social factors affect how we behave in social situations.” Social factors play a big part in a person’s overall mental health. According to the NIMH, studies show that the following social factors are routinely linked to increased psychological distress:

  • Employment conditions
  • Unemployment
  • Precarious employment
  • Hostile interactions with empoyers
  • Lower incomes
  • Poor quality housing conditions
  • Food insecurity and poor diet
  • Discrimination
  • Familial relationships (both negative and positive)
  • Racial/ethnic minority status
  • Immigration status

The above are examples of social factors that have been studies that can effect a person’s mental health. Here are some factors your biopsychosocial assessment may want to focus on related to social factors:

  • Family relationships
  • Social support structure
  • Employment status
  • Marital status
  • Hobbies and activities
  • Living situation
  • Military service
  • Legal history
  • Financial information
  • Education background

Questions to Include to Assess Social Factors

Below are some specific questions we ask in our biopsychosocial assessment template pertaining to social factors:

  • Please list out your family members (parents, children, brothers, sisters, etc.)
  • Has a significant person or family member entered into your life or left your life in the last 90 days?
  • How are the relationships with your family members? Please describe
  • How are the relationships in your support circle (friends, extended family, etc.)? Please describe
  • Have there been any problems with your family in the past (abuse, conflicts, stress, loss, etc.)? Please describe
  • Are there any problems with your family now (abuse, conflicts, stress, loss, etc.)? Please describe
  • Have there been any problems with your support circle in the past? Please describe
  • Are there any problems with your support circle now? Please describe
  • What is your marital status now?
  • Have you ever had problems in your marriage or relationships?
  • Do you have any close friends?
  • Do you have problems being in friendships?
  • Do you get along well with others (neighbors, co-workers, people around you, etc.)?
  • What do you like to do for fun / in your spare time? Please explain
  • Have you ever been arrested?
  • If yes, did you serve time in prison or a corrections facility?
  • Please check the highest level you completed in school
  • Would you describe your schooling experience as a positive?
  • Are you currently in school or in a training rogram?
  • What is your work history like?
  • How long do you usually stay in your job?
  • Are you retired from working?
  • Do you feel financially secure?
  • Have you ever served in the military?

Getting answers to these questions will help you understand social factors that may be influencing your clients’ conditions.



Streamlining your Biopsychosocial Assessment into an Editable PDF Template

Gathering important biopsychosocial information is crucial to making proper assessments and creating an effective treatment plan. How you collect information can dramatically influence the speed at which you assess and help your client. If you’re using pencil and paper, you may be spending too much of your valuable time that can be spent better helping clients.

Benefits of Our Biopsychosocial Assessment Template Doc PDF

Our biopsychosocial assessment template allows you to:

  • Take in responses from clients on a digital device like a computer
  • Organize client documents in an easy to find folder on your computer or in the cloud
  • Search for specific questions and/or answers by using “CTRL + f” function on your keyboard
  • Legibly read your client’s answers
  • Print copies that are high in quality

Download our editable biopsychosocial assessment template PDF below:

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Download our editable biopsychosocial spiritual assessment template PDF below:

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Thank you for reading our article on “Writing an Effective Biopsychosocial Assessment [Editable PDF Template].” If you’re a mental health professional, we’d love for you to join our community that connects patients with mental health professionals like yourself.

Anthony Bart
Author: Anthony Bart

Anthony Bart is a huge mental health advocate. He has primarily positioned his marketing expertise to work with mental health professionals so that they can help as many patients as possible. He is currently the owner of BartX, TherapistX, and TherapyByPro.

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