Therapy Biophychosocial Assessment

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?

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

Please list your medications and dosages below.

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:

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:

Kristin Snowden