Southern New Hampshire University
HSE 350 Biopsychosocial Assessment and Diagnos c Interpreta on
Biopsychosocial Assessment
Client Name: Joe Smith Evalua ng Counselor: Kristen Hughes
Date: 5/23/22
Instruc ons: Use this document to record the client interview. Insert "NA" if the ques on/sec on is not
Presen ng Problem: (Include the client's own words about why the services are needed, any referrals, and major stressors over the past six months.What are the posi ve and nega ve conseguences of not using? Include client's current primary drug use with age of rst use, pa ern, dura on, and intensity.) Client reports that he is a self-referral. Client reports that this is his rst me in inpa ent treatment. Client reports that he has been to several outpa ent programs with no success at long term recovery. Client reports that he has been using and is homeless staying with friends. Client reports he is currently not speaking with his family. Client reports that he lost his job and was arrested for bouncing checks. Client reports that he is currently on proba on for a year and is required to do treatment for the charge. Client reports the only family support that he had was his aunt and she passed from cancer.
Past Treatment History: (Include past treatment history for substance abuse AND mental health services.) counselors, IOPs, and NA mee ngs.
Family History: (Include biological family members, number of children, divorce, and separa ons. Describe what it was like growing up in this family and include substance abuse and psychiatric history of family members.) Client reports that it was him his mom, dad, and sister in the household. Client reports that his uncle also was living with him and his family. Client reports that his father passed away when the client was 16. Client reports that his father was abusive. Client reports that his mother and father were heavy drinkers. Client reports he does not know about his sister's drug or alcohol use. Client reports that he was sexually abused by an uncle at the age of 14.
Substance Use History Top three drugs of choice: heroin Marijuana Tobacco
Substance Type
Age of Route of Amount Frequency First Administra on Used of Use Use
Date of Last Use
Treatment Where/When
Alcohol
14
oral
n/a
n/a
n/a
n/a
Southern New Hampshire University Inhala on/ n/a n/a n/a n/a Smoking
Cocaine
1tt
Marijuana
16
smoking
n/a
Occasionall n/a y
n/a
Heroin
21
injec on
fi-10 bags
Daily
n/a
n/a
Other Opiates
21
n/a
n/a
n/a
n/a
n/a
BZs
n/a
n/a
n/a
n/a
n/a
n/a
Methadone
n/a
n/a
n/a
n/a
n/a
n/a
Suboxone
n/a
n/a
n/a
n/a
n/a
n/a
Tobacco
n/a
Smoking
V2-1 pack
Daily
n/a
n/a
Withdrawal Symptoms: (List any withdrawal symptoms as reported by client--e.g., sweats, cons pa on, DTs, seizures.) Sweats, goose pimples, running nose, cramps.
Social History Current Life Situa on: (Summarize present living arrangements and any current social supports.) Client reports that he has been couching sur ng and liv