What is a biopsychosocial assessment?

A biopsychosocial assessment is an approach therapists use to gather biological, psychological, and social factors that impact a client’s thoughts, feelings, and behaviors. It’s based on Engel’s biopsychosocial theory, which suggests a person’s well-being stems from multiple factors. Through this assessment, you can understand a client’s strengths while also evaluating vulnerabilities or struggles that may contribute to their mental health symptoms.

In either case, it’s a helpful tool for better understanding, diagnosing, and treating your clients. “People don’t live in a vacuum, and this approach helps you get a clear and complete image of the client on multiple different planes in a short time,” says Michael Heckendorn, a licensed therapist and Headway’s clinical lead of clinical education.

What’s included in a biopsychosocial assessment?

A biopsychosocial assessment typically addresses three key components of a person’s life.

Biological questions

The assessment usually includes questions about a person’s medical history, including health conditions, medications, and lifestyle habits.

Psychological questions

You’ll also ask questions about a person’s mental health history, including past diagnoses, therapy experiences, and psychiatric medications.

Social questions

Finally, the assessment incorporates questions about a person’s social history, including about relationships with their family, friends, and colleagues or classmates.

How to format a biopsychosocial assessment

You can gather biopsychosocial information through your intake forms or conduct an interview during an initial intake, or a blend of the two, explains Heckendorn. To get the clearest picture of your client, you could send the forms to your client before the session, review their answers, and then use the intake to ask follow-up questions.

Biopsychosocial assessment example/template

Headway uses an asynchronous form you can send out prior to the intake session.

Reasons for seeking care

What brings you to therapy?
Are you seeking a medication evaluation?
What goals do you have for this treatment?

Current symptoms

What symptoms have you experienced in the last 30 days? For example, have you experienced symptoms of depression or anxiety?
Are you a survivor of trauma?

Substance use

Do you regularly use any form of tobacco?
Would you or someone you know say you have a problem with alcohol use?
Pills or illegal drugs?
Other addictions, like gambling, pornography, or shopping?
Is there a history of addiction in your family?

Personal, family, and relationships

How are your relationships with your family members?
Have there been any problems with your family in the past or currently, such as abuse, conflicts, stress, or loss?
How are your relationships with your extended support circle, such as with friends, classmates, or colleagues?
Have there been any problems with your support circle in the past?
Anything else about your family and social relationships you want to add?

Education

What is the highest level of education you have completed?
Would you describe your schooling experience as positive overall?
Are you currently in a school or training program?

Work

What do you do for work?
How long do you usually stay in a job before moving to something else?
What’s your military status?

Medical history

Are you allergic to any food or medications?
What current and past medications have you taken?
Are you currently pregnant?
Do you have a primary care physician? If so, who?
What past and current medical problems have you had, including any relevant surgical procedures?

Mental health history

Have you seen mental health professionals previously? If so, when and who?
Have you previously received a diagnosis from a mental health provider? If so, what?
Are you currently attending or have you ever been to a self-help group?
What current and past psychiatric medications have you taken?
Do you experience side effects or adverse reactions?
Have you ever attended an Intensive Outpatient Program or Partial Hospital Program?

Other

Is there anything else you’d like to share?

What to do with the results of a biopsychosocial assessment

Understanding your client on a holistic level can help you determine whether you’re the best therapist for a particular client. It can also help you connect back to their goals for treatment and inform what therapy looks like, such as what interventions and modalities you may apply to reach those goals.

If a person presents with concerns you aren’t equipped to treat, you can refer them to another therapist. If you continue with therapy, then the biopsychosocial assessment helps inform your diagnosis and in turn, create your treatment plan.

A more comprehensive view of your client equips you to better identify their struggles and the therapeutic approach they may benefit from. “You can also understand the protective factors and support in their lives and encourage those in therapy,” says Heckendorn.

Compliance and documentation