Review Josh’s recorded video of his intake interview with therapist Dr. Amy Wenze

CNL-605: Biopsychosocial Assessment Template

 

Client’s Name:	Date:
DOB:	Age:
Start Time:	End Time:

 

 

Identifying Information:

 

 

 

Presenting Problem/Chief Complaint:

 

 

 

Substance Use History:

 

 

 

 

 

Addictions (i.e., gambling, pornography, video gaming):

 

 

 

Medical History/Mental Health History/Hospitalizations:

 

 

 

Abuse/Trauma History:

 

 

 

Social History and Resources:

 

 

 

Legal History:

 

 

 

 

 

Educational History:

 

 

 

Family History:

 

 

 

Cultural Factors:

 

 

 

Resources, Strengths, and Weaknesses:

 

 

 

Case Conceptualization (Conceptualize the case using your preferred theoretical orientation):

 

 

Clinical Justification:

 

 

 

Initial Diagnosis (DSM-5):

Principal Diagnosis:	ICD-10 Code:	DSM-5 Disorder:	Subtypes:	Specifiers:
Provisional Diagnosis:	ICD-10 Code:	DSM-5 Disorder:	Subtypes:	Specifiers:

 

Initial Treatment Goals Informed by Theoretical Orientation (SMART Goal Format):

Goal # 1:
Objectives:	Interventions:	Target Date:
1.
2.
Goal # 2:
Objectives:	Interventions:	Target Date:
1.
2.

 

Student Clinician’s Name:

Date: