Bio-Psychosocial Assessment

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Bio-Psychosocial Assessment, Intervention, and Evaluation Plan with Individuals and Families Limestone College
Social Work Practicum 2011
Troy A. Bowers
Dr. Chuck Kuhn

BIO-PSYCHOSOCIAL ASSESSMENT

Consumer Identification
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Consumer NameClient Record #: GRIN122682
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Last: Grier First: Natalie Middle:
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Date of Birth: 12/26/1982 Age: 29 Medicaid ID #: 5555555 Not Medicaid Enrolled -------------------------------------------------
Applied for Medicaid (Date):      

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Gender
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Female Male
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Ethnicity
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M (Hispanic Mexican American)
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C (Hispanic Cuban)
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P (Hispanic Puerto Rican)
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N (Not Hispanic)
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H (Hispanic Other)
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Race
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W (White)
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B (Black/African American)
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A (Asian)
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I (American Indian or Alaska Native)
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P (Native Hawaiian or other Pacific Islander)
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U (Unreported)
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Marital Status
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Never Married (S)
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Married (M)
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Annulled (A)
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Separated (P)
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Divorced (D)
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Widowed (W)
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Domestic Partners (L)
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Primary Language
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English (E)
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Sign Language (L)
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French (F)
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Spanish (S)
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Other (O)
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None (N)
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Unknown (U)
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Consumer Residence
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01 Private Residence
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Alone With Others
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02 Other Independent
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03 Homeless
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04 Correctional Facility
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05 Institution
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06 Residential Facility (Not Nursing)
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07 Foster Family/AFL
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08 Nursing Home (ICF, SNF)...
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