Professional Practices:
Assessment
Melody Kipp, PhD, LMHC
Life & Work Soulutions, Inc.
Assessment

An ongoing process through which the
counselor collaborates with the client
and others to gather and interpret
information necessary for planning
treatment and evaluating client
progress, and making substance abuse
diagnoses. (Florida Certification Board,
2004, p. 27).
Assessment

The Biopsychosocial Interview.

The purpose of the Biopsychosocial
interview is to find out exactly what the
problems are and where they come from.
Biology – the cells.
 Psychology – the emotions, attitudes, and
behavior.
 Sociology – the relationships and environment.

Assessment
The Biopsychosocial Assessment
(Appendix 32)
 Allow 1 to 2 hours:

Without distractions
 Without interruptions

Assessment

Beginning counselors often experience
difficulty with the assessment because:
They become overwhelmed with too much
information.
 They begin treatment too early.


Becoming a skilled interviewer takes
practice and experience.
Assessment

The biopsychosocial assessment should
address the following:
The patient’s demographic information.
 History of present illness.
 Past history.
 Medical history.
 Mental status exam.

Assessment

Imagine yourself sitting in a
comfortable chair in your office. You are
relaxed and ready to begin the
Biopsychosocial Interview with the
client sitting across from you. What will
you say to the client as you begin the
Biopsychosocial Interview?
Assessment

After you have completed the practice
interview, reflect on these questions:
How did you feel after the interview was
completed?
 What part of the interview was effortless
for you?
 What part required more effort than you
thought?
 Where do you believe you could improve?

Assessment

Ask the person you interviewed to give
you some constructive feedback on how
they felt during the interview and what
they thought went well and what could
use improvement.
Assessment

You may also want to enlist the help of
a seasoned professional counselor to
observe you conducting the
Biopsychosocial interview. That person
could then offer you more constructive
criticism that will help you improve your
clinical skills.
Assessment

Look at the completed Sample
Biopsychosocial Interview in Appendix
7. Using that sample as a guide, write a
narrative summary of your interview
using the following headings:
Patient Name
 Demographic Data

Assessment
Chief Complaint
 History of the Present Illness
 Past History
 Medical History
 Family History
 Mental status

Assessment

Summary and Impressions

Include all of the problems that you have seen
and give your impression of where the patient
stands on each of the following dimensions:






Acute intoxication or withdrawal complications
Biomedical conditions or complications
Emotional/behavioral complications
Treatment acceptance or resistance
Relapse potential
Recovery environment
Assessment

Diagnostic Impressions:


Based on the information gathered during
the Biopsychosocial Interview, a diagnosis
is determined by consulting the DSM. What
are your diagnostic impressions of your
“pretend” client?
Reminder: Only licensed clinicians or
those supervised by licensed clinicians
may diagnose patients.