Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Biopsychosocial Assessment Form Template

Streamline patient evaluations with our biopsychosocial assessment form

Struggling to gather comprehensive patient information? Our biopsychosocial assessment form template helps healthcare professionals like you evaluate a patient's biological, psychological, and social factors effectively. By using this template, you can ensure thorough assessments that lead to better diagnosis and treatment plans, improve communication with patients, save time on paperwork, and maintain compliant records that meet WCAG standards. Explore the live template to see how it works for you.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email
Phone number
Emergency contact name
Emergency contact phone
Preferred contact method
Phone
Email
Text message
No contact
Briefly describe your main concern or reason for seeking services
What are your primary goals for care?
How long has this been a concern?
Less than 2 weeks
2-4 weeks
1-3 months
3-6 months
More than 6 months
Unsure
Current medical conditions (diagnoses or concerns)
Current medications (name, dose, frequency)
Allergies (medications, foods, environmental)
Overall sleep quality in the past 2 weeks
Poor
Below average
Average
Good
Exceptional
Substances used in the past 30 days (select all that apply)
Current symptoms (select all that apply)
Have you received mental health treatment in the past?
Yes
No
Types of past treatment (if any)
Outpatient therapy
Psychiatric medication
Inpatient hospitalization
Intensive outpatient or partial program
Support group or peer support
School counseling
Not applicable
Other
Please Specify:
In the past month, how often have you had thoughts of suicide?
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Current relationship status
Single
In a relationship
Married or partnered
Separated or divorced
Widowed
Prefer not to say
Do you have children or dependents?
Yes
No
Current housing situation
Stable housing
Temporary housing
Staying with friends or family
Shelter or homeless services
Homeless or unsheltered
Prefer not to say
In the past 12 months, how often did you worry that food would run out before you had money to buy more?
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Employment or education status
How would you rate your available social support?
Very low
Low
Moderate
High
Very high
Prefer not to say
Personal strengths and resources
Coping strategies that help you
Cultural or religious considerations you would like your provider to know
Accessibility or accommodations needed (select all that apply)
Wheelchair access
Interpreter or translation
Large print
Telehealth or video sessions
None
Other
Please Specify:
I consent to receive services from this provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I consent to be contacted outside sessions via (select all that apply)
Phone
Voicemail
Text message
Email
Do not contact me outside sessions
Date of consent
I permit the provider to contact my emergency contact if necessary
Yes
No
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Gender identity","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a biopsychosocial assessment form template for FormCreatorAI article.

When to use this form

Use this intake when you onboard new clients in mental health, social work, primary care, or rehab. Capture history, symptoms, and social context at the first visit so you can set a focused plan and referrals. For complex presentations, add a Psychiatric evaluation form to document mental status and diagnoses. If depression is a concern, pair it with the PHQ-9 Rating scale form to quantify severity and track change. It also fits annual reviews, level-of-care decisions, or preauthorization summaries. You save time, reduce back-and-forth, and spot risks early, which leads to clearer goals and more consistent outcomes.

Must Ask Biopsychosocial Assessment Questions

  1. What brought you here today, and what are your top goals?

    This focuses the session and reveals what matters most to the client. Clear goals guide your treatment plan and help you measure progress.

  2. Over the past two weeks, how have your mood, anxiety, sleep, and energy changed?

    Trend data improves clinical decisions and flags urgent needs. If symptoms are significant, the Hamilton depression rating scale form helps you standardize severity and monitor progress.

  3. What medical conditions, medications, and substances (including alcohol or drugs) affect your health?

    Biological factors and interactions can drive or worsen symptoms. This question prevents safety issues and guides referrals or coordination with medical providers.

  4. What supports and stressors do you have at home, work or school, and in your community?

    Social factors often sustain problems or enable change. Knowing them helps you target resources like housing, employment, or family support.

  5. Have you experienced trauma, current safety concerns, or thoughts of self-harm?

    Direct screening identifies risk and shapes your safety plan. If trauma is present, the PTSD Checklist - civilian version (PCL-C) form supports structured screening and follow-up.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel