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Students will print out the biopsychosocial assessment prior to watching the documentary Love Them First: Lessons From Lucy Laney Elementary and will use this form to practice completing a biopsychosocial assessment as you watch the documentary.  In particular, as you fill out the assessment, pay close attention to the young girl, Sophia, and the impact the adults, especially Principal Mauri Melander-Friestleben, have on Sophia and the other children at the school.  It is expected that many will be a novice in this activity and this is where I would like you all to challenge yourselves in doing something that may feel foreign. This is meant to be a practice exercise so you can become acquainted with the assessment, explore any insights you may have from undergrad classes, other classes you’re taking, personal or professional experience in completing this assessment.  It is encouraged that students take notes along the way of any missing knowledge that would enhance their ability to complete this assessment or questions they have about the assessment.

Upload your assessment along with 3 questions you have about administering biopsychosocial assessments for your classmates to review. The instructor will lurk in the discussion board and may offer feedback/answers/clarification, but I will be waiting to see what you offer one another. The grading for this DISCUSSION BOARD is specific to your completion of the discussion, not the quality of your biopsychosocial document. 

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:

A. Appearance, grooming/hygiene, size/weight, is clothing appropriate to the weather/setting

B. Ability to participate/Effort made/Motivation

C. Orientation (who, what, where, day, date, time)

D. Cooperation/Attitude

E. Attention, posture, Eye Contact, psychomotor agitation or retardation

F. Speech (rate, tone, volume, content, fluidity, accent)

G. Affect and its congruence with mood

H. Mood (as they describe it and your assessment)

I. Memory (does it appear intact, did you do memory test, obvious problems? Consider short and long-term)

J. Thought Process (logical, linear, tangential, circumstantial, etc)

K. Thought Content (bizarre, typical, appropriate to the setting and situation, etc)

L. Perceptual Disturbances, hallucinations, loss of rational thinking, suicidal/homicidal

M. Judgment

N. Insight

7. Clinical Impressions (theories with rationale)

8. Recommendations (interventions with rationale)