Therapy Biophychosocial Assessment

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Kristin Snowden: Therapist, Life Coach, Author

Therapy Biopsychosocial Assessment

Kristin Minto-Snowden, MA, LMFT, CDWF
Lic. Marriage & Family Therapist #81413
5743 Corsa Avenue, Suite 221
Westlake Village, CA 91362

General Information

First Name

Last Name

Address

City

State

Zipcode

Phone

I agree to recieve emails from Kristin.

Date of Birth

Occupation

Marital Status

Employer

Will you be requesting out-of-network reimbursement?

Yes

How may Kristin contact you? (Select as many as you're comfortable with.)

Phone

Text

Postal Mail

Emergency Contact Name

Emergency Contact Phone

What is their relationship to you?

Gender at birth

Gender Identity

Sexual Orientation

Do you have children?

Yes

Yes (non-biological)

Please list their names, ages & genders

What concerns/issues led you to seek treatment?

Do you have any specific goals with regard to your therapy?

Do you have any fears or hesitations relate to recieving therapy?

Medical Information

Have you experienced any significant medical issues (i.e. accidents, surgeries, illness)? Please describe.

Are you currently taking any medications?

Yes

Who is your prescribing doctor?

Please list your medications and dosages below.

Do you ever take more than prescribed?

Have you ever attempted suicide? if so, when?

Are you currently experienceing suicidal thoughts?

Yes

Do you smoke? if so, how many years have you smoked?

Do you drink alcohol? if so, how often and how many years have you been drinking?

Do you use illegal/recreational drugs (i.e. marijuana, cocaine, meth)? If yes, please describe your use.

Family History

Describe your childhood.

If married or in a primary relationship, please describe it:

If married or in a primary relationship, please describe your partner:

Please describe your current/immediate family:

Additional Information

Please describe your spiritual identity/orientation:

Please describe your interests or hobbies:

Describe your strengths:

Describe your weaknesses:

Any additional information that you’d like share:

I declare that the info I’ve provided is accurate & complete to the best of my knowledge.

Your Signature

Today's Date

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