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Theresa M. Cukierski, LLC
1070 Commerce Drive, Building One, Suite 204
Perrysburg, Ohio 43551
Phone: 419.276.4416
Fax: 419.874.4691
Child/Adolescent Biosocial Inventory
The Biosocial Inventory is a confidential form used by mental health clinicians to gather
information regarding a client’s biological and social background. This information is used in
assistance to the client’s treatment and will be kept in their confidential chart. Please take your
time and answer each question carefully. If the client is of an appropriate age and capacity,
please complete the form with the client.
Referral Source: ________________________________________________________________
Name of person completing this form: ______________________________________________
Relationship to client: ___________________________________________________________
Demographic Information
Client Name: __________________________________________________________________
Date of Birth: ___________________Age: ___________________________________________
Sex: __________________________Gender: _________________________________________
Nation/Tribe/Ethnicity: __________________________________________________________
Primary/Secondary Language: _____________________________________________________
Religious/Spiritual Identity, if any: _________________________________________________
Name of School: _______________________________________________________________
Grade Level: ___________________________________________________________________
Any special education or learning problems? ____ Yes
____ No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Parent(s) Name(s): ______________________________________________________________
Address: ______________________________________________________________________
Phone Number: ________________________________________________________________
Marital Status:
____ Single ____ Dating ____ Married ____ Separated
____Divorced ____ Widowed
Does the parent or parents listed above have custody of the client? ____ Yes
____ No
If not, please provide the name, phone number, and address of the person/agency who has
custody:
______________________________________________________________________________
______________________________________________________________________________
Does the client live at the above address? ____ Yes ____ No
If not, please list client’s address and phone number:
______________________________________________________________________________
______________________________________________________________________________
Health Information
Client’s approximate weight: __________ height: __________
Have there been recent weight changes: ____ Yes ____ No
If yes, please identify the amount lost or gained: ______________________________________
Over what period of time? ________________________________________________________
List all important past or present illnesses, injuries, disabilities, or limitations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Rate client’s physical health:
____ very good
____ good
____ average ____ poor
____ other (explain):
______________________________________________________________________________
______________________________________________________________________________
Primary Care Physician Information:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Phone Number: ________________________________________________________________
Date of client’s last medical examination: ____________________________________________
Is the client currently taking any medication? ____ Yes
____ No
If yes, please identify the medication, dosage, and frequency of use (i.e. Zoloft, 25mg, Daily):
______________________________________________________________________________
______________________________________________________________________________
Prescribed by (name, phone number, and address if different than PCP above):
______________________________________________________________________________
______________________________________________________________________________
History of psychiatric hospitalization? ____ Yes
____ No
If yes, specify when and where:
______________________________________________________________________________
______________________________________________________________________________
Has the client received counseling services in the past? ____ Yes ____ No
If yes, please identify the counselor and approximate date(s) of treatment:
______________________________________________________________________________
______________________________________________________________________________
Has the client ever used street drugs or alcohol? ____ Yes ____ No
If yes, please identify the substance(s) and pattern of use:
______________________________________________________________________________
______________________________________________________________________________
Social and Familial Information
Has the client had involvement with the law? ____ Yes
____ No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
Is this a current issue? ____ Yes
____ No
Children’s Services Involvement: ____ Past ____ Present ____ Never (check all that apply)
Please explain involvement:
______________________________________________________________________________
______________________________________________________________________________
Please identify any of client’s current interests (i.e. creative writing, sports, volunteering, etc.):
______________________________________________________________________________
______________________________________________________________________________
Briefly describe client’s social patterns (i.e. makes friends easily, isolates self, bullied, etc.):
______________________________________________________________________________
______________________________________________________________________________
Familial Information
Please identify family members:
Name
Age
Relationship to
Client
Quality of
Relationship
(poor, fair, good, excellent)
Significant person(s) in client’s life not listed above:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please identify any past or current pertinent family information (i.e. deaths, traumas, adoptions,
medical issues, substance abuse, frequent moves, economic hardships, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Person(s) client is closest to: ______________________________________________________
Person(s) client is least close to: __________________________________________________
Comments:
______________________________________________________________________________
______________________________________________________________________________
Self-Descriptive Information
Check any of the following words which you and/or client believe apply to the client now:
(Identify any differences in opinion between person filling out form and client with initials)
____ outgoing
____ independent
____ controlling
____ suicidal
____ often blue
____ moody
____ quiet
____ likable
____ impulsive
____ untrustworthy
____ compliant
____ victimized
____ emotional
____ restless
____ confident
____ dependent
____ nice
____ distant
____ confused
____ bored
____ misunderstood
____ aggressive
____ unreliable
____ competent
____ naïve
____ anxious
____ easily influenced
____ worthless
____ leader
____ active
____ lost
____ shy
____ serious
____ creative
____ guilty
____ assertive
____ intelligent
____ hopeful
____ critical
____ hyperactive
____ lonely
____ sensitive
____ imaginative
____ talented
____ angry
____ unconcerned
____ dishonest
____ hopeless
____ worn down
____ calm
____ depressed
____ hardworking
____ impatient
____ passive
____ hostile
____ ambitious
____ self-conscious
____ detached
____ superior
____ inferior
List your 5 main fears:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What are your personal strengths?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please circle the answer that best describes the client’s current situation (adolescents only)
1. I get along well with others
2. I tire quickly
3. I feel little interest in things
4. I blame myself for things
5. I feel irritated
6. I have headaches
7. I feel stressed
8. I feel lonely
9. I feel fearful
10. I have thoughts of ending my life
11. I feel worthless
12. I am a happy person
13. I am concerned about family troubles
14. I work/study too much
15. I have frequent arguments
16. I feel loved
17. I enjoy my free time
18. I have difficulty concentrating
19. I feel hopeful about the future
20. I like myself
21. I have disturbing thoughts I can’t get rid of
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
never
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
often
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
22. I have an upset stomach
never
23. I have trouble getting along with my friends
never
24. I am satisfied with my life
never
25. I have sore muscles
never
26. I am afraid of open spaces, driving, or being on buses never
27. I feel nervous
never
28. I have regrets about things in my life
never
29. I have trouble falling or staying asleep
never
30. I feel something is wrong with my mind
never
31. I feel sad
never
32. I feel angry enough to do something I may regret never
33. I have too many disagreements with others
never
34. I am satisfied with my relationships
never
35. I am content with my spiritual life (if applicable) never
36. My heart pounds too much/too fast
never
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
rarely
some
some
some
some
some
some
some
some
some
some
some
some
some
some
some
often
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often
often
often
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often
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often
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often
always
always
always
always
always
always
always
always
always
always
always
always
always
always
always
Problem Analysis
Problem Description: Briefly describe the issue(s) that the client and you would like addressed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Problem Intensity: Rate the intensity level of the problem or concern:
____ not intense
____ moderately intense
____ extremely intense
Problem Duration: How long has the client had the current problem or concern?
______________________________________________________________________________
______________________________________________________________________________
Coping Attempts: In what ways has the client attempted to cope with the problem or concern?
______________________________________________________________________________
______________________________________________________________________________
Upon the completion of treatment, what do you hope to have accomplished (i.e. goals for
treatment)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature: ________________________________________________ Date: _______________
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