Writing a Bio-Psycho-Social Report
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.
Name: Jane Doe
Collateral: John Doe (Uncle)
Age: 9 years old
Date of birth: xx/xx/xxxx
Dominant Hand: Right
Ethnicity: Ethnicity A/Ethnicity B
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.
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.
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.”
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).
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.
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.
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.
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.
Jane and her Uncle deny any family history of substance abuse.
Jane does not report any legal history or involvement.
Client’s Uncle does not report any history of trauma or other significantly stressful incidents.
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.
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.
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.
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.