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Writing a Bio-Psycho-Social Report

Updated on July 26, 2014

Assessment

After asking all question included in your agency's form, writing up the information in a manner that will help to infer the assessed needs of the client and inform what interventions will be used to achieve those needs is crucial in treatment planning and in developing an Individualized action Plan (IAP).

The example below is the report I did after interviewing a friend's niece who was free of Psychopathology. It provides a nice template for organizing the necessary information to be included and demonstrates the proper wording and interpretation of the data collect.

All identifying information has been altered.

Example

Demographic Information

Name: Jane Doe

Collateral: John Doe (Uncle)

Age: 9 years old

Gender: female.

Date of birth: xx/xx/xxxx

Dominant Hand: Right

Ethnicity: Ethnicity A/Ethnicity B

Chief Complaint

Client complains of boredom and inactivity since the commencement of summer break.

History of Complaint

For approximately the past three weeks Jane has been experiencing boredom associated with her summer break from school, per client report. She relates that she has just been “hanging around the house all day,” mostly watching television.

Education

Jane reports that she just completed fourth grade with good marks (3’s and 4’s on a 4 point grading scale). That she is in a regular learning population classroom and has never had to repeat a grade and reports no attendance problems. She relates that she enjoys school, “when she’s feeling it,” and has had some limited behavioral problems related to anger.

Social

She reports having friends whom she talks to and plays games with. She states that she gets along well with them, “sometimes,” aside from occasional fighting about small issues that she could not recall the nature of. She has a 5-year old brother, a 13-year old sister and a 3-year old cousin that she also reports fighting with over small issues. She also is responsible for chores at home such as doing the dishes, sweeping, and cleaning the bathroom, per client report. When she does not complete these tasks she relates that she is not allowed to go outside and this makes her feel, “mad.”

Family

Jane lives with her Mother, three Aunts, Grandmother, Grandfather, 5-year old brother, 13-year old sister, and 3-year old female cousin. She reports that the three year old cousin causes some disruptions in the household that, “drive her crazy.” Although she assented to the author’s statement that she usually likes it at home she reports that sometimes she would like to spend more time with her Aunt on her father’s side (who lives outside the home).

Developmental History

Jane’s Uncle reports that she was born during a normal delivery without complication after a healthy pregnancy and that she was walking at about 18 months while meeting all other developmental milestones approximately on schedule.

Medical History

Jane and her Uncle report that she has no history of hospitalizations, surgeries, head injuries, seizures, losses of consciousness, and is not on any medications. She did relate once having Bronchitis which cleared with a course of antibiotics and one emergency room visit resulting from a puncture wound to the foot from stepping on a nail.

Family Medical History

Client’s Aunt reports that Jane’s maternal Grandmother and Grandfather suffer from COPD and that both her maternal and paternal Grandfathers have diabetes. Her paternal Grandfather also has a history of cancer that is currently in remission. They report no other significant family medical issues.

Health Behaviors

Jane reports sleeping approximately 6-8 hours a night often going to bed around midnight in the summer and waking around seven or eight. She reports a healthy appetite and a diet consisting of chicken, rice, beans, spinach, and green beans. She relates that she has to do exercise (push-ups, jumping jacks) as punishment for misbehavior sometimes.

Psychological History

Jane reports having to complete an anger management class which she enjoyed but did not find helpful. She has no other history of significant behavioral problems, psychological diagnosis, or outpatient counseling.

Mental Status Exam/Observations

Jane denies any suicidal ideation. She did not deny any thoughts about ever hurting or killing others but denied any planning or serious intent. She reports no hallucinations or delusions, (as described by the author). Her thought content, affect, speech, posture, appearance, and insight are all within normal limits. She was cooperative with the interviewer if not a little nervous and reticent at times. She presented as casually dressed and groomed. She demonstrated admirable patience throughout the interview process for her age.

Family psychological History

Jane and her Uncle deny any family history of Psychological issues.

Drugs/Alcohol

Jane and her Uncle deny any family history of substance abuse.

Legal History

Jane does not report any legal history or involvement.

Trauma History

Client’s Uncle does not report any history of trauma or other significantly stressful incidents.

Recreation/Strengths

Jane reports spending her leisure time engaged in riding her scooter, playing games on her phone, and reading. She also plays tennis and basketball for her school.

Her Uncle describes her as a very nice person who does what she is asked and will further do anything for people she is close to without asking for anything in return.

Clinical Interpretation

Jane is a physically healthy nine-year old girl of A and B Ethnicity. She is doing well academically and has a full and supportive family life. Though she has some anger issues that have caused some problems at school and home she seems to be free of psychopathology and to have a normal quantity and quality of social connection with her peers. She has healthy sleeping, eating, and exercise habits and a very sweet disposition. She has never experienced any trauma or neglect and is developing well socially and emotionally.

Recommendations

Jane's issues with anger control should continue to be monitored by her family and school and if either feels that she could benefit from further anger management skills or counseling then this should be discussed. However, at this time no counseling interventions seem necessary in the author’s opinion.

Summing Up

As far as Psychometric assessments go the Bio-Psycho-Social clinical interview is toward the highly unstructured side with limited reliability and validity. But for clinicians who work at agencies with limited resources it does provide a holistic conceptualization of a client and their reason for presenting for therapy. All information pertinent to therapy will only fully come to light after working with a client for a more extended period of time but this intake assessment measure provides a point from which to begin.

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    • vrbmft profile image

      Vernon Bradley 3 years ago from Yucaipa, California

      Nice format. A tad too clinical to the point you could have been reporting about an ax murder! No flavor of the 9 year old girl! And I'm surprised there was no mention of dad and the impact of his absence, perhaps part of the source of her anger! Loss always entails anger!