Biopsychosocial Assessment for Clinical Intake

Welcome! This intake helps your care team understand your health, mood, and life circumstances together — not just one piece at a time. It takes about 6-8 minutes. Your responses are completely confidential and anonymized. Please answer as honestly as you can; there are no right or wrong answers.

Before we begin, please review this statement.

Right now, how would you rate your overall physical health?

Over the last 2 weeks, how would you rate each of the following?

Please list any current medical conditions, medications, or ongoing treatments (write 'none' if not applicable).

In the last 30 days, how often have you used alcohol or other substances to cope with stress or emotions?

• Never
• Rarely
• About once a week
• Several times a week
• Daily

Over the last 2 weeks, how would you rate your overall stress level?

In the last 2 weeks, how often have you experienced each of the following?

Which best describes your current living situation?

• Living alone
• Living with family or a partner
• Living with roommates
• Temporary, shared, or unstable housing
• Currently without stable housing

In the last 30 days, how often have money worries affected your ability to cover basics like food, housing, or medication?

• Never
• Rarely
• Sometimes
• Often
• Almost always

What is the single biggest source of stress in your life right now?

Using the respondent's answer about their biggest current stressor, explore how it connects to their physical health, mood, and living situation — ask how it affects their sleep, daily functioning, or relationships, and what they've already tried to manage it. Anchor on any specific frequency or scale answers they gave earlier (sleep, stress, mood, financial strain) and ask them to walk through one concrete recent example. If the respondent expresses thoughts of self-harm, hopelessness, or safety concerns, do not attempt to counsel or diagnose — acknowledge it, gently ask if they are safe right now, and encourage them to contact a crisis line or their care provider before continuing.

What is your age range?

• Under 18
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65+
• Prefer not to say

How do you describe your gender?

• Woman
• Man
• Non-binary
• Prefer not to say

What is your current employment status?

• Employed full-time
• Employed part-time
• Unemployed and looking
• Unable to work
• Retired
• Student
• Prefer not to say

Thank you for sharing all of this. Your responses will go directly to your care team to help build a plan that fits your whole life, not just one part of it.