Biopsychosocial Assessment
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10CHILDREN / ADOLESCENETS (Age 17 and under)
SOCIAL / MEDICAL HISTORY
BIOPSYCHOSOCIAL ASSESSMENT
Please answer all questions, do not write in boxes labeled psychologist use only. Thank you.
Child’s Name: __________________________________________
Date: ____________________
Child’s age: ________ Date of Birth: ____ / ____ / ______ Sex (circle one):
Male
Female
Address: _____________________________________________________________________________
Street
_______________________________________
_________________
___________________
City
State
Zip
Phone: (Home) _________________________________ (Cell) _________________________________
Person filling out form: ___________________________________________________________________
Name of person responsible for bill: ________________________________________________________
Emergency Contact: _____________________ Relationship ________________ Phone ______________
Parents / Stepparents
Mother’s name: _______________________ Age: _____ Education: _________ Occupation: _______________________
Father’s name: ________________________ Age: _____ Education: _________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Marital status of parents: ____________________ If parents are separated/divorced, how old was child at time of
separation? ___________________
With whom does the child live? ___________________________________________________________
Custody: Lives in one home with both legal parents. Mother has physical custody.
Father has physical custody.
Physical custody is shared.
Other: ___________
List all people living in household:
Name
Age
Relationship to child
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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