SW660 Biopsychosocial Assessment Outline

SW660 Biopsychosocial Assessment Outline

Table of Contents

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Instructions

SW660 Biopsychosocial Assessment Outline

Biopsychosocial Assessment Outline for SW660 (revised January 2022)

Please use the same headings to divide the content but do not use the letters in the details of the outline; rather, write the information in a narrative (sentence) format.

The following areas must be addressed in the assessment.

1. Demographic Data

Date, name, age, sex, race, source of income, marital status, living arrangements, etc.

2. Presenting Problem

Pertinent details of who is the client and why are they there. What’s the problem, how long has it lasted, do they have a theory of what’s happening, is it related to something, have they had this problem (or similar) in the past, etc.

2. Family History

Brief summary of childhood, born and raised, were parents married, with whom did you live growing up, who did you feel closest to, extended family relationships, are there family members you avoid or aren’t speaking to, significant relationships, how many times married/divorced, number of children and ages.

3.  Education and Work History/Military
4.  Psychiatric and Medical History

Mental health history and current situation. Medications and doses, taking as prescribed or not, history of suicidal/homicidal ideation, describe attempts, history of abuse, current stressors (deaths, divorce, financial, etc.)

5.  Substance Use History

Is there any use of alcohol, tobacco, vaping, misuse of prescribed medications, illicit use of prescriptions, street drugs, other chemicals such as huffing and over the counter meds like cough medicine or stuff you buy at gas stations?

Ask about each category of drugs and document first use, method of use, current use, last use. If there’s current use, how often and how much. Tobacco, Alcohol, cannabis, stimulants for attention, anxiety medications, sleep medications, pain medications/opioids, illicit drugs such as cocaine, heroin, methamphetamine, hallucinogens. Any history of treatment, history of problems with withdrawal, including seizures, DT’s, requiring medically monitored detox, family history of substance use problems. Be sure to note any periods of abstinence and recovery. What did they do for support?

6. General Observations and Mental Status:
7. Appearance, grooming/hygiene, size/weight, is clothing appropriate to the weather/setting
8. Ability to participate/Effort made/Motivation
9. Orientation (who, what, where, day, date, time)
10. Cooperation/Attitude
11. Attention, posture, Eye Contact, psychomotor agitation or retardation
12. Speech (rate, tone, volume, content, fluidity, accent)
13. Affect and its congruence with mood
14. Mood (as they describe it and your assessment)
15. Memory (does it appear intact, did you do memory test, obvious problems? Consider short and long-term)
16. Thought Process (logical, linear, tangential, circumstantial, etc)
17. Thought Content (bizarre, typical, appropriate to the setting and situation, etc)
18. Perceptual Disturbances, hallucinations, loss of rational thinking, suicidal/homicidal
19. Judgment
20. Insight
21. Clinical Impressions (theories with rationale)
22. Recommendations (interventions with rationale)

RUBRIC
Excellent Quality 95-100%	Introduction 45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The searcSW660 Biopsychosocial Assessment Outlineh history is mentioned.		Literature Support 91-84  points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is SW660 Biopsychosocial Assessment Outlinementioned.			Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score 50-85%	40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.		83-76  points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.			52-49  points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality 0-45%	37-1 points The background and/or significance are missing. No search history information is provided.		75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.			48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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