Biopsychosocial Assessment and Goal Setting 1

Biopsychosocial Assessment and Goal Setting

Darice Collier
Wayne State University













Biopsychosocial Assessment and Goal Setting 2

Presenting Problem:
Bianca Berry (pseudonym) is a 23 year old African American female, who is engaged and has
one child (male, age 1). Ms. Berry and her fianc have known each other for eight years, dated
for a year, and have been engaged for a year. Ms. Berry and her fianc are currently living
together in a house and have been living together for one year. She attended college after she
graduated from high school and has not graduated due to many reasons. Her fianc has a child
(female, age 2) that is one year older than her child and she currently moved with them. Ms.
Berry is coming to see a social worker due to the stress she is dealing with because of her
difficulties trying to graduate from school while trying to maintain her child, fianc, job, school,
house, help assist with her fiancs daughter and help her disabled mother.
Family of Origin History:
Ms. Berrys mother was 24 years old when she gave birth to her and Ms. Berrys parents were
married to each other. She has five sisters, Tiffany who is 27 years old is currently unemployed,
Marissa who is 20 years is a student in college, currently employed at a restaurant, Kiara who is
14 years old is unemployed and Leya who is 13 years old is unemployed. None of her sisters are
married and does not have any children. One of her sisters she does not know anything about
and have not seen her for 15 years. All of the pregnancies that Ms. Berrys mother had were not
planned. The age of her mother is 47 and the age of her father is 48. Her parents are currently
divorced and they were divorced 17 years ago due to her father cheating on her mother with a
plethora of women. Her father also had a child with another woman while they were married.
There was a good atmosphere in the household where Ms. Berry lived when she grew up. Her
parents took really good care of her and her siblings. All of her provisions were met by her
Biopsychosocial Assessment and Goal Setting 3

parents. When her mom and dad divorced she spent a lot of her childhood and adolescent years
helping her mom care for her siblings. Ms. Berry stated that all the holidays that her family spent
together were fun and a great enjoyment. There are always home cooked meals and many
deserts that are delicious. They always were at her grandmothers house, her mothers house, or
one of aunties houses. Ms. Berrys mother and father both graduated from high school. Her
father also graduated from a police academy and her mother also graduated from a business
vocational school. Marissa and Tiffany both graduated from high school and Kiara and Leya
both are currently attending middle school. Marissa is currently attending college as well. The
health of the clients siblings is good and her father. Her mother health is good, but she does
have a few problems. Her mother is considered to be disabled because she is not capable of
working. She have problems with walking for a long period of time, she has high blood
pressures, and have a herniated disk. The concept of death in the family is that when a person
dies the person is with God in heaven. The way the family address death is by having a funeral
for any deceased person and the person is buried. The clients family does not believe in
conducting cremations.
Developmental History:
The clients mother carried Ms. Berry full term before she gave birth to her. She was delivered
vaginally when her mother was 39 weeks and weighed 6 pounds and 3 ounces. The client
suffered with yellow jaundice after she was born, she was treated by having a blood transfusion
and being the incubator for 2 weeks. The clients mother bottle fed Ms. Berry and there were no
feeding issues. There were not any developmental delays and the client learned everything at an
average age.
Biopsychosocial Assessment and Goal Setting 4

Health History:
Ms. Berry stated that she has good health and she had average health during her childhood. She
started her menstrual cycle at the age of 12 and always had cramping issues when she has her
menstrual cycle. Ms. Berry did not have any childhood surgeries, chronic illnesses, accidents, or
broking bones. Ms. Berry has not had any adult surgeries, chronic illnesses, accidents, broken
bones or weight issues while in her adulthood.
Relationship/Sexual History:
Ms. Berry has a few friends and those friends are her colleagues from college. She only has one
friend that she had in her childhood and they are currently still friends. She has been friends
with her colleagues for 4 four years and friends with her childhood friend for 10 years. Client
stated that she is heterosexual and begin dating when she was 17 years old due to her mother
being strict. Her first sexual encounter was when she was 20 years old. She stated that she was
not scared to have sex and she just wanted to make sure it was the right person. She also stated
that her first couple experiences were not enjoyable, but she eventually sex became pleasurable.
She also wanted to be married when she lost her virginity, but it did not happened that way. She
has never use any birth control contraceptives; just condoms and she have not had any sexual
transmitted diseases. Her fianc is the guy she first encountered sex with.
Family of Creation History:
Client has never been married and has only been in one long term committed relationship that
she is currently in. Her fianc is the only guy she has been in a relationship with. He is 24 years
old and they had a son together named Kylen that is one year old. Her satisfactory in her
relationship is good and she thinks that he treats her well. She is happy while she is in her
Biopsychosocial Assessment and Goal Setting 5

relationship and wants to marry him. Ms. Berry stated that she has a wonderful relationship with
her son and he is well disciplined. Her fianc attended college for three years and he is working
on getting his nursing degree. She stated he is currently working in a factory making a descent
amount of money. Her pregnancy with her son was not planned and she delivered him vaginally.
Religious History:
Ms. Berrys religion is Christianity and that is what her family origin of religion is. She stated
that Christians believes that Jesus is their savior and he is the son of God. Christians goals are to
be like him because he is way to follow. Her religion is very important to her and her family.
She stated that she has been a Christian since she was born and she is happy about it. She is
active in her church, she is on the usher board, she praise dances, and she also helps serve food
for any church activity.
Educational History:
Ms. Berry graduated from Kettering high school that is located in Detroit. She is currently
attending Oakland University to obtain her degree in physical therapy. She stated that she is
smart and motivated to finish school.
Employment History:
Ms. Berry has worked a few minimum wage paying jobs and the total number of jobs she
worked are four. She worked at her high school office while she attended high school her senior
year, she worked at a restaurant, and she worked at a grocery store. Client stated that she
enjoyed working at all her jobs, especially when she worked during high school. She is currently
working at a grocery store 40 hours per week and she enjoys being a cashier. She stated she
Biopsychosocial Assessment and Goal Setting 6

loves greeting the customers and ringing up their groceries. Some of the customers only come to
her register when she is working because they think she is the best cashier. Even though she
loves her job, she wants a new job with a better pay.
Financial History:
While growing up her family finances were good and her family received everything that was
needed. Her parents were able to afford nice home, nice cars, and every provision needed.
Strengths:
Ms. Berry stated that she is a strong minded person and she stays positive about any situation.
She loves to help people and most people ask her for advice. She believes she can do anything
she puts her mind to. Client states that she is good at cooking and baking foods. She also has
great communication skills. Ms. Berry has a supportive fianc and family that assist her with any
help she needs.







Biopsychosocial Assessment and Goal Setting 7


Step 1: Working with the Client
Ms. Berry confided in me some issues that she wants me to assist her with.
The issues are the following:
1. The supervisor at her job is mean to her, the other workers, and sometimes the customers.
2. She wants her fianc and her to have a better relationship.
3. She needs someone else to watch her child while she is working.
4. She is stressed from school.
Step 2: Prioritize the Problems
1. She is stressed from school work.
2. She does not have a babysitter for her child.
3. Conflict with her supervisor.
4. She has relationship problems with fianc.
Step 3: Translate Problem into Need
Problem
1. She is stressed from school work.
2. Her child does not have a babysitter.
3. Conflict with her supervisor.
4. She has relationship problems with fianc.
Need
1. Get assistance with school.
2. She needs babysitter for her child.
3. Resolve conflict with supervisor.
Biopsychosocial Assessment and Goal Setting 8

4. Resolve relationship issues with fianc.
Step 4: Evaluation Levels of Intervention for Each Need
Goal Number 1- Find babysitter for her child.
Objective 1 Look on the internet for child daycares within one week.
Task 1 Ask family and friends for suggestions within one week.
Task 2 Visit the daycares you think are good within one week.
Objective 2 Visit academic advisor and ask about school daycare programs witin one week.
Task 1 Visit the daycare programs within one week.
Task 2 Ask colleagues about daycare programs within one week.
Goal Number Two- Resolve relationship issues with fianc.
Objective 1 Find a relationship therapist in one week.
Task 1 Research the internet for therapist in 3 days.
Task 2 Speak with therapist and ask about their practice in 4 days.
Objective 2 Talk to fianc about seeing a therapist in 2 week weeks.
Task 1 Ask fianc about attending some sessions in 2 weeks.
Task 2 Ask fianc when he can visit the therapist in 2 weeks.
Goal Number Three- Resolve conflict with supervisor.
Objective1 Set up a meeting with supervisor in one week.
Task 1 Talk to supervisor about concerns in 3 days.
Task 2 Schedule a meeting in 5 days.
Objective 2 Tell the store manger about the issues in 2 weeks.
Task 1 Set up a meeting with the store manager in one week.
Task 2 Talk to the store manager about concerns in 6 days.

Biopsychosocial Assessment and Goal Setting 9

Goal Number Four- Get assistance with school.
Objective 1 Discuss school concerns with the school advisor in one week.
Task 1 Call the school advisor in 3 days.
Task 2 Schedule a meeting with school advisor in 3 days.
Objective 2 Find a good tutor in 5 days.
Task 1 Research tutors on the internet in 2 days.
Task 2 Call tutors to ask about their credentials in 3 days.
Task 3 Go to the school library and ask for list of tutors on 2 days.

















Biopsychosocial Assessment and Goal Setting 10

Contract for Intervention Plan
Client Name: Bianca Berry
Description of the Problem: Ms. Berry is in need of help with school, her child, conflict
resolution skills, and relationship skills. She also needs assistance with better career options.
Primary Goals:
1. Get assistance with school.
2. She needs babysitter for her child.
3. Resolve conflict with supervisor.
4. Get help with her fianc relationship.
We the undersigned, agree to the objectives in the following plan:
A. Go to the library for tutor assistance within 1 week.
B. Locate a child daycare in 2 weeks.
C. Set up a meeting with supervisor within 1 week.
D. Locate a relationship therapist office within 2 weeks.
Signature of Client_____________________________________ Date___________
Signature of Worker____________________________________ Date___________