Biopsycosocial assessment for family.

Biopsycosocial assessment for family.


  1. Identifying Information
  2. Demographic Information:


Race: Hispanic

Sex: Female

Marital Status: Married

Employment: Works as an Attorney

Physical environment/housing: Lives with Husband and child

  1. Referral Information:
  2. Referral Source: Was referred to my office from the court house.
  3. Any other Professional or indigenous helpers currently involved: Currently client is involved with the probation department.
  4. Data sources used in writing this assessment:
  5. Interviews with others involved:Husband
  6. Tests performed: Drug test 1 year ago for driving under the influence of alcohol. She was drug tested again when she was arrested recently for driving under the influence of alcohol.
  1. Presenting Problem:
  2. Description of the problem: Alcohol use.
  3. What precipitated the current difficulty?Client states that she drinks every day after work 5 to 6 days out of the week.
  4. What feelings and thoughts have been aroused?AnaKarenstates that she drinks to relieve the stress from work.
  5. How has the client coped so far? Still continues to drink.
  6. Who else is involved in the problem?AnaKaren’s husband and child. Also AnaKaren’s employment.
  7. How are they involved? Husband and child have to see AnaKaren at home when she is intoxicated. AnaKaren’s employer sees a decline in her job performance the days after she has drank alcohol.
  8. How do they view the problem?AnaKaren’s Husband doesn’t want AnaKaren to drink anymore, and her employer has requested that she receive treatment or she will no longer be able to go back to work.
  9. How have they reacted?AnaKaren’s husband is disappointed that she has not been able to control her drinking.No, current reaction from employer other than they would like her to seek treatment.
  10. How have they contributed to the problem or solution? Both AnaKaren’s husband and employer want her to get the treatment she need to overcome her alcoholism.
  11. Past experiences related to current difficulty:
  12. Has something like this ever happened before?Yes, was arrested 1 year ago for driving under the influence of alcohol.
  13. If so, how was it handled then?AnaKaren was sentenced to spend 6 days in jail and suspension of her driver’s license for 18 months.
  14. What are the consequences?18 months driver’s license suspension


III.           Background History:

  1. Developmental history: alcohol use when she was 15 years old and has been abusing alcohol for 10 years
  2. Family background:
  3. Description of family of origin and current family: Parent’s still alive but doesn’t have strong relationship with them. AnaKaren is the oldest of three and the only daughter. Two younger brothers and they are in the army.
  4. Extent of support: The only support AnaKaren has is from her husband.
  5. Family perspective on client and client’s perspective on family: The only family perspective is from her husband who wants to see AnaKaren get the treatment she needs. Client perspective of the family is that she only has support from her husband and not her parents.
  6. Family communication patterns: AnaKaren’s communication patterns have been good with her husband, but her communication patterns with her parents are not well.
  7. Family’s influence on client and intergenerational factors: There has been no family influence on client due to AnaKaren’s parents do not drink. Her husband doesn’t drink only on social gatherings.
  8. Intimate relationship history: AnaKaren has been with her husband since college. There has been no other intimate relationships.
  9. Educational and or Vocational training: College graduate
  10. Employment history: Works as an Attorney
  11. Military history: None
  12. Use and abuse of alcohol or drugs, self, and family: Anakaren has abused alcohol for 10 years since the age of 15. Anakaren’s parents do not drink.  Anakaren’s husband drinks but only on social gatherings.
  13. Medical history:
  14. Birth information: AnaKaren was born healthy in Harlingen, TX
  15. Illnesses: none
  16. Accidents: AnaKaren broke her hand at work about a 1 year ago.
  17. Surgery: none
  18. Allergies: none
  19. Disabilities: none
  20. Health problems in family: none
  21. Nutrition: AnaKaren and her family eat well.
  22. Exercise: Anakaren says she tries to exercise at least twice a week, but sometimes is unable too due to heavy workload.
  23. Sleep: AnaKaren goes to sleep very late due to up all night drinking and working on her cases.
  24. Mental Health History:
  25. Previous mental health problems and treatment: No, previous mental health problems.
  26. Hospitalization: None
  27. Outcome of treatment: None
  28. Family mental health issues: None
  29. Nodal events:
  30. Deaths of significant others: There has been no significant deaths.
  31. Serious losses or traumas: There has been no significant losses or traumas.
  32. Significant life achievements: Graduated from College and became an attorney.
  33. Cultural background:Hispanic
  34. Race/ethnicity: Hispanic
  35. Primary language/other languages spoken: English and Spanish
  36. Significance of cultural identity: AnaKaren still follows the same norms as those of her earlier generations. Her parents don’t drink, but her grandparents would at family gatherings.
  37. Cultural strengths:
  38. Experiences of discrimination or oppression: None
  39. Migration experience and impact of migration on individual and family life cycle:Anakaren experience and impact of migration has been that she saw her parents struggle with low paying jobs that lead them to migrate some of the time during school. Anakaren states that she didn’t want to live a life as her parents did so she finished college and became an attorney.
  40. Religion:
  41. Denomination: Anakaren is a Catholic but doesn’t actively practice due to workload.
  42. Church membership: None
  43. Extent of involvement: Doesn’t actively practice due to work.
  44. Spiritual perspective: Anakaren’s spiritual perspective is that she believes there is a God.
  45. Special observances: None
  1. Assessment:
  2. What is the key issue or problem from the client’s perspective?Client doesn’t think she has a problem from her perspective.
  3. From the worker’s perspective? From the workers perspective I believe client does have an alcohol abuse disorder, and would require some type of counseling and group support.
  4. How effectively is the client functioning?Client states she is able to function well. I believe that the client is in denial and doesn’t realize she has an alcohol abuse disorder.
  5. What factors including thoughts behaviors, personality issues, environmental circumstances, stressors, vulnerabilities, and needs seem to be contributing to the problem? (use systems theory with ecological perspective as a framework):AnaKaren states that she has some stress from work, and also with financial stability due to medical bills from a fall at work that caused her to break her hand. Using the systems theory I would say Anakaren falls under the dynamic systems theory because her life is constant dynamic movement and because her problems and issues are forever changing due to her work type. The ecological perspective would be social environment because AnaKaren environment involves the conditions, circumstances, and human interactions that encompass human beings to survive and thrive.
  6. Identify the strengths, sources of meaning, coping ability, and resources that can be mobilized to help the client. I believe AnaKaren has the strength to overcome the alcohol use disorder.  She needs to find a different type of coping ability to relieve stressors in her life.
  7. Assess client’s motivation and potential to benefit from intervention: At this time client doesn’t have any potential motivation due to she was sent from the court for treatment.  Client believes she doesn’t have a problem which will be a challenge for client and myself to aid in treatment.
  1. Recommendations/Proposed Intervention:
  2. Tentative Goals (With measurable objectives and tasks)
  3. One short term: Attend AA Meetings and group support meetings
  4. One long term: For client to refrain from alcohol use for 4 months
  5. Units of attention
  6. Possible obstacles and tentative approach to obstacle: A possible obstacle for the client is that she is use to drinking alcohol when she comes home from work.  Client would have to try and refrain from alcohol use when she gets home from work. Client would also have to try and find a positive outlet to relieve stress.

Treatment Plan:

Goal: Refrain from engaging in Alcohol use

Need to Problem: Stop the Alcohol abuse


Who:     What:    When:  Completed by:


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