Scenario: Loss of a Family Member

Casey is a 21-year-old Hispanic man who is seeking counseling. In your first session with him, he states that he is unsure of how to go back to life the way it was before and finish his bachelor’s degree in business after losing someone he admired and looked up to. Casey reports that he recently lost his mom in a traffic accident 3 weeks prior. He states that everything he did in life was because his mom had inspired him and motivated him towards becoming who is today. He is an only child and does not have a very good relationship with his father.

He reports that the morning of the accident, he overslept and did not see his mom before she left for work and didn’t tell her he loved her. He reports that he has a lot of remorse over that, and he constantly wonders if things may have been different if he woke up on time and delayed her for a couple of minutes.

Casey states that he has been unable to focus on his schoolwork and his grades are declining. He has trouble with motivation and seeing the point of going to class. He doesn’t sleep well at night and wakes up early in the morning with a feeling of panic. His heart is racing, and his chest is heavy; he breathes heavily and feels a sense of fear or dread. Casey hasn’t been eating well, and he doesn’t work out like he used to. He wants to talk to his friends, but he feels like a burden. He ruminates over the fact that he didn’t get to say goodbye or tell his mom he loved her. He states that he tries to talk to his friends, but they don’t understand, and they tell him that it’s time to “get over it.” He has tried to talk to his father and was hoping to strengthen their relationship, but his father has been very distant. He does not feel like he has a good support system, and he states that he just wants someone to understand what he is going through.

Casey appears restless and agitated during sessions and has trouble keeping his body still, shifting his weight often. He starts to say something but then forgets what he was saying. He can give a clear timeline, and he is expressive of his thoughts and feelings. He is tearful when talking about the loss but shows more frustration or anger at himself when talking about the events of that day. He appears more agitated with friends or his father and their lack of empathy.

Casey has been a good student in the past and has always had friends in his life. He experimented with marijuana one time in high school and has had a few beers but never was “the partier type” and still isn’t. He had clear goals for the future. He cherished his mom, and even though he wasn’t as close to his dad he loved him. Now he feels like everything he had from the past has crashed and gone away.

 

Biopsychosocial Assessment (Blank Form)

Client Interview

Identifying Information

Begin by completing the basic demographic information for your client.

• Name(s): Enter your response.
• Date of birth: Enter your response.
• Primary language: Enter your response.
• Referred by: Enter your response.
• Intake date: Enter your response.
• Evaluated by: Enter your response.

Description of Client(s)

Briefly describe what you observe about the client’s physical status: age, gender, ethnicity, appearance, behaviors, and any impressions that stand out to you.

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Presenting Problem

Briefly describe why the client is seeking counseling.

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History of Problem

Describe the symptoms, experiences and background of the problem, previous occurrences, and interventions in a brief paragraph.

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Social History

Describe the client’s social support system in a few sentences, including the following:

• where the client lives and with whom
• quality of relationships with family and friends
• support received from others

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Family History

Describe the client’s family of origin and relationships with family in the past and present in a few sentences.

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School History

Briefly describe the client’s educational background and any relevant school history or experiences, including the following:

• where the client went to school
• years of education completed
• positive or negative experiences of school

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Work History

Describe the client’s relevant work history and experiences in a few sentences, including the following:

• current employment situation
• time spent in the career/profession
• positive or negative experiences of work
• any sporadic work history or frequent job changes

 

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Spiritual

Briefly describe the client’s stated spiritual beliefs.

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Legal

Indicate whether the client has current or previous legal issues. If current, what is the status? Is the client on probation, etc.?

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Trauma History/Abuse

Describe any past or current traumatic events or abusive situations that the client may have experienced. Indicate whether this is ongoing and if the client has received counseling in the past for it.

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Suicidal/Homicidal

Indicate if the client has had any suicidal or homicidal thoughts, plans, or attempts. Note if these are in the past or present and if they are passive or active. If client currently has suicidal or homicidal thoughts, complete a full suicide risk assessment. If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

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Health and Wellness History

Discuss client’s past and present substance use, sleep habits, exercise and eating habits. Ask direct questions to gather this self-explanatory information.

Substance Use

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Sleep Habits

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Exercise Habits

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Eating Habits and Appetite

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Mental Status

Assess your client’s mental status by discussing what you observe about the client in your session.

Activity

Describe the client’s behaviors, especially the physical movement of the client.

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Mood and Affect

Describe the client’s mood and affect (visible expression of feelings and emotions).

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Thought Process, Content, and Perception

Describe the client’s thought process, content, and perception in how they respond to questions and tell their story.

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Cognition, Insight, and Judgment

If completed, indicate any results of a Mini Mental Status Exam (MMSE) in this section. Discuss whether the client appears to understand the symptoms and issues being experienced.

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Case Summary

Legal and Ethical

Discuss any potential legal or ethical issues you need to consider as the counselor; this is not about the client having a legal issue.

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Strengths

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to use resources.

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Challenges

Describe aspects of the client’s life circumstances that may impede progress or change, such as homelessness, major psychiatric disorder, financial hardship, etc.

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Discussion

Summarize the presenting problem and symptoms, along with any pertinent history and social factors that lead to a diagnosis. This section justifies your diagnosis; include any differential diagnoses here.

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Diagnosis

Using the information gathered thus far, make a diagnosis using the DSM-5. Include the diagnostic title and code, as well as any specifiers.

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Assessments to Support Diagnosis

Identify any assessments that have been used or that you might use to support a diagnosis or rule out a differential diagnosis.

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Case Conceptualization

Explain the issues, symptoms, and diagnosis of the case through the lens of a theoretical perspective.

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