COU 645 Biopsychosocial Assessment
Indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE
ANY SECTION/LINE BLANK.
Client Name:
Date:
SECTION I
Introduction/Client Summary:
Presenting Problem: (Include the client’s own words about why the services are needed and
how the primary problem is affecting the client, including behavioral, cognitive, emotional, and
physiological symptoms; analyze the life span of the client for appropriate sexual development.)

Family History: (Include biological family members, describe what it was like growing up in this
family, and include substance-abuse and psychiatric history of family members if appropriate.)
Medical Health/Biological History: (Include illnesses, surgeries, and medications. Note any
current medical problems, physical disabilities, and/or eating disorders. Include development
throughout the life span and include any areas of concern.)
Allergies:
Medications: (Include name of medication, dose, condition it is treating, and its effectiveness—
OTC and prescription.)
_____________________________________ ___________________________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
Mental Health/Psychiatric History:
Has client ever been treated for a psychiatric illness:
Yes
No
Please explain: (Include if client had been hospitalized, seen by a mental health professional,
what they were seen for, and how long they were seen.)
SECTION II
Psychosocial History and Cultural Identity
Current Life Situation: (Summarize present living arrangements and any current social
supports.)
Sexual Orientation:
Spiritual Beliefs:
Family Influence: (How does the client’s/parent’s cultural identity influence the client’s
perceptions of the problem?)
Educational History: (Note highest level of schooling completed, school performance, peer
relationships, and learning problems.)
Client Strengths:
1.
2.
3.
SECTION III
Summative Conceptualization: (This narrative section pulls all of the information together from
the biopsychosocial history, with a clinical opinion about what the primary issues are and what
should be done to address them. Also state potential referrals that are appropriate at this
time.)
Diagnostic Impression: (Identify whether the issue is part of age- and gender-appropriate
development or a sexual disorder, and use the DSM to justify your conclusion.)
Goals (Identify one of each.)
Short-Term Goal:
Long-Term Goal:
Technique/Intervention: (Propose one technique or intervention to support the client in
accomplishing the therapeutic goals.)
Clinician/Counselor Signature: ____________________________________ Date: ___________
COU 645 Final Project One Guidelines and Rubric
Overview
The first final project for this course is the creation of a comprehensive case conceptualization based on the Final Project Case Study. The final product
represents an authentic demonstration of competency because you will develop a diagnostic impression and preliminary treatment goals through
comprehensive analysis of the presenting problem with consideration for cultural factors. Throughout the course, you will participate in various activities that
will support your development of the comprehensive case conceptualization. These practice activities will be submitted at various points throughout the course
to scaffold learning and ensure quality final submissions. The final product will be submitted in Week Nine. The final comprehensive case conceptualization
should be completed as a psychosexual history form that you start in Week Two by completing a summary of the client.
In this assignment, you will demonstrate your mastery of the following course outcomes:




COU-645-02: Analyze the life span of a client for informing appropriate sexuality development during case conceptualization
COU-645-03: Distinguish developmentally appropriate sexuality issues with sexual disorders or mental illness to support the client during a counseling
session
COU-645-04: Determine ethical and cultural considerations that address sexuality issues for a specific client during a counseling session
COU-645-05: Integrate comprehensive assessment of sexuality for establishing case conceptualization while working with a client with sexuality issues
Prompt
Specifically, you must address the critical elements listed below. Most of the critical elements align with a particular course outcome (shown in brackets).
Comprehensive Case Conceptualization
I.
Introduction/Client Summary
A. Summarize the client. [COU-645-03]
II.
Biopsychosocial History
A. Summarize the client’s biopsychosocial history. While doing this, consider if the client had appropriate development throughout his life span.
[COU-645-02]
B. Determine areas of clinical concern in the client’s biopsychosocial history. [COU-645-03]
III.
Cultural Identity
A. Discuss how the client’s cultural identity influences the client’s perception of the issues. [COU-645-04]
B. Identify any cultural or ethical concerns that you would need to take into consideration while working with the client. [COU-645-04]
1
IV.
Presenting Problems
A. Describe the primary problem, issue, or challenge to be addressed in the therapeutic process. [COU-645-05]
B. Explain how the primary problem, issue, or challenge is affecting the client. [COU-645-05]
i.
Consider the following when reviewing the presenting problems:
 What are the behavioral symptoms?
 What are the cognitive symptoms?
 What are the emotional symptoms?
 What are the physiological symptoms?
V.
Diagnostic Impression
A. Identify whether the issue is part of age- and gender-appropriate development. If not, is it a potential sexual disorder? [COU-645-02]
B. Use the DSM-5 to justify your conclusion. [COU-645-03]
VI.
Potential Treatment Focus
A. Summarize two potential therapeutic goals for the client:
i.
Short-term goal [COU-645-05]
ii.
Long-term goal [COU-645-05]
VII.
Proposed Technique/Intervention
A. Propose one technique or intervention to support the client in accomplishing the therapeutic goals. [COU-645-05]
Practice Activity
Practice Activity: Biopsychosocial Assessment
In Week Two, you will submit the summary portion of a biopsychosocial assessment form for your selected client. This activity will directly support your final
project by helping you summarize the information in your case study and identify key elements regarding the client. You will build upon this information
throughout the course while participating in the weekly activities. This activity will be graded with the Week Two Case Study Assignment Rubric.
Final Project One Submission: Comprehensive Case Conceptualization
In Week Nine, you will submit your first final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It
should reflect the incorporation of feedback gained throughout the course. The final product itself is a completed biopsychosocial assessment form. This
submission will be graded with the Final Project One Rubric.
2
Final Project One Rubric
Guidelines for Submission: Your comprehensive case conceptualization should be 4 to 7 pages in length and formatted as a clinical document that uses the
Biopsychosocial Assessment document. Use double spacing, 12-point Times New Roman font, and one-inch margins.
Critical Elements
Client Summary
[COU-645-03]
Biopsychosocial
History: Summary
[COU-645-02]
Biopsychosocial
History: Clinical
Concerns
[COU-645-03]
Cultural Identity:
Influences
[COU-645-04]
Cultural Identity:
Cultural or Ethical
[COU-645-04]
Presenting Problems:
Primary Problem, Issue,
or Challenge
[COU-645-05]
Presenting Problems:
Affecting the Client
[COU-645-05]
Exemplary (100%)
Meets “Proficient” criteria and
uses industry-specific language
to establish expertise
Meets “Proficient” criteria and
uses industry-specific language
to establish expertise
Meets “Proficient” criteria and
demonstrates sophisticated
awareness of clinical concerns
Proficient (90%)
Summarizes the client
Needs Improvement (70%)
Summarizes the client but lacks
detail or clarity
Not Evident (0%)
Does not summarize the client
Value
8.37
Summarizes the client’s
biopsychosocial history
Does not summarize the client’s
biopsychosocial history
12.50
Does not determine areas of
clinical concern in the client’s
biopsychosocial history
8.37
Meets “Proficient” criteria and
demonstrates a sophisticated
awareness of how cultural and
ethical concerns could impact
counseling sessions
Meets “Proficient” criteria and
demonstrates sophisticated
awareness of how the client’s
culture could impact counseling
sessions
Meets “Proficient” criteria and
demonstrates sophisticated
awareness of how the client’s
primary problem, issue, or
challenge could impact
counseling sessions
Meets “Proficient” criteria and
shows in-depth knowledge of
how the primary problem,
issue, or challenge is affecting
the client
Discusses how the client’s
cultural identity influences the
client’s perception of the issues
Summarizes the client’s
biopsychosocial history but
lacks detail or contains gaps
Determines areas of clinical
concern in the client’s
biopsychosocial history but
lacks detail or contains gaps
Discusses how the client’s
cultural identity influences the
client’s perception of the issues
but lacks rational
Does not discuss how the
client’s cultural identity
influences the client’s
perception of the issues
12.50
Identifies any cultural or ethical
concerns that would need to be
taken into consideration while
working with the client but
lacks detail or contains gaps
Describes the primary problem,
issue, or challenge to be
addressed in the therapeutic
process but lacks detail or
contains gaps
Does not identify any cultural or
ethical concerns that would
need to be taken into
consideration while working
with the client
Does not describe the primary
problem, issue, or challenge to
be addressed in the therapeutic
process
11.59
Explains how the primary
problem, issue, or challenge is
affecting the client, but
assessment is incomplete or has
gaps
Does not explain how the
primary problem, issue or
challenge is affecting the client
4.02
Determines areas of clinical
concern in the client’s
biopsychosocial history
Identifies any cultural or ethical
concerns that would need to be
taken into consideration while
working with the client
Describes the primary problem,
issue, or challenge to be
addressed in the therapeutic
process
Explains how the primary
problem, issue, or challenge is
affecting the client
3
4.02
Diagnostic Impression:
Appropriate
Development
[COU-645-02]
Meets “Proficient” criteria and
illustrates a sophisticated
explanation
Identifies whether the issue is
part of age- and genderappropriate development
Diagnostic Impression:
DSM-5 Justification
[COU-645-03]
Meets “Proficient” criteria and
illustrates a sophisticated
explanation of the diagnostic
impression
Meets “Proficient” criteria and
the description of the goal is
exceptionally clear and
contextualized
Meets “Proficient” criteria and
the description of the goal is
exceptionally clear and
contextualized
Meets “Proficient” criteria and
the description of the technique
or intervention is exceptionally
clear and contextualized
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented in
a professional and easy-to-read
format
Uses the DSM-5 to justify the
diagnostic impression
Potential Treatment
Focus: Short-Term Goal
[COU-645-05]
Potential Treatment
Focus: Long Term Goal
[COU-645-05]
Proposed
Technique/Intervention
[COU-645-05]
Articulation of
Response
Identifies whether the issue is
part of age- and genderappropriate development but
does not cover all required
elements
Uses the DSM-5 to justify the
diagnostic impression but
contains inaccuracies
Does not identify whether the
issue is part of age- and genderappropriate development
11.59
Does not use the DSM-5 to
justify the diagnostic impression
8.37
Summarizes a short-term goal
Summarizes a short-term goal,
but it contains unattainable or
irrational expectations
Does not summarize a shortterm goal
4.02
Summarizes a long-term goal
Summarizes a long-term goal,
but it contains unattainable or
irrational expectations
Does not summarize a longterm goal
4.02
Proposes a technique or
intervention
Proposes a technique or
intervention, but it contains
unattainable or irrational
expectations
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas
Does not propose one
technique or intervention to
support the client in
accomplishing therapeutic goals
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
4.02
Total
100%
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
4
6.61
COU 645 Biopsychosocial Assessment
Indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE
ANY SECTION/LINE BLANK.
Client Name: Devin
Date: 1/16/22
SECTION I
Introduction/Client Summary:
Client is 8-year-old natal male, Devin of Caucasian parents Teresa and Richard who are married
for 14 years and of the middle-class socioeconomic status. Teresa describes their marriage as
traditional and her description of their marital relationship implies a patriarchal dynamic.
Client’s father has a rigid parenting style and says that the bible and the belt make the rules in
their house. While the mom Teresa is more permissive and presents as a loving parent, she
yields to the directives of her husband and work to avoid conflict at all costs. Teresa worries
about how strict her husband is. Teresa brought him in for counselling because both she and his
dad think something is wrong with him because he shows a pervasive tendency to do things like
a girl and that when client is encouraged to participate in activities that are typically associated
with boys, Devin would become upset and scream a refusal or withdraw and sulk. When
church member began to comment about the behavior, his father Richard insisted that ha gets
some help. Client’s mother admits that both she and the father were embarrassed by the
comments and snickering of fellow church members and that has propelled them to take
action.
Teresa reported that client had no birth issues, medical issues or psychological issues and has
historically thrived in school. She reported client’s effeminate behavior is tossing his hair like a
girl, never expressed interest in in any contact sports or rough-and-tumble play “like boys are
supposed to” According to Teresa, when he was 4 years old he would express that he wants to
grow up to be a woman, insists on sitting to urinate, refuses to wear boys underwear and
reports that “he doesn’t like the hole in the front. Devin refers to his penis as disgusting,
frequently asks if he can if he can dress up with his sister’s princess costumes, wear scarfs on
his head pretending it is hair and wears makeup. His fantasy pay typically involves playing
female roles such as mother.
Presenting Problem: (Include the client’s own words about why the services are needed and
how the primary problem is affecting the client, including behavioral, cognitive, emotional, and
physiological symptoms; analyze the life span of the client for appropriate sexual development.)
The parents believe the services is need because they are worried that “something seems to be
wrong” with Devin for acting like a girl and these behaviors areas long as the mother can
remember. The parents believe it is something he would grow out of, so they tolerated the
behavior at home and associated it with having only female siblings to play with. Teresa admits
that she and Richard are embarrassed by the comments and snickering of fellow church
members and that’s what propelled them to take action. Devin’s pervasive tendency to do
things like a girl, his effeminate manners and body movements more like a girl than a boy his
age. Sitting to urinate and refusal to wear boys’ underwear and prefers panties saying, “he
doesn’t need a hole I the front”. He refers to his penis as disgusting and often ask his mother if
he can dress up in her clothes. Routinely plays dress up with his sister’s princess costumes. He
regularly wears a towel on his head pretending to be long hair, he enjoys putting on makeup
and playing dress up, with a typical fantasy play of being the female such as a mother. Devin
prefers to play with his sisters he struggles to play with boys in class at school and chooses to sit
in classroom lunch. He very affectionate towards his mother but avoidant of his father. He
loves visiting his maternal grandmother because she is very loving allows Devin to play freely as
he chooses.
Family History: (Include biological family members, describe what it was like growing up in this
family, and include substance-abuse and psychiatric history of family members if appropriate.)
Devin’s father Richard has always been the primary financial provider and has been married to
Teresa for 14 years and has two younger daughter ages 6 and 4. Client’s paternal grandparents
are both alive and lives in California which prohibits Devin to visit frequently Devin’s parents
reported to be very traditional with a patriarchal marital dynamic. Teresa worries about how
strict Richard is, but defers to him in accordance with their conservative Christian views. The
entire family attends a Baptist church every Sunday and Wednesday. Teresa teaches vacation
bible school in the summer and is active in the “women’s” circle. The family had no report of
substance-abuse and psychiatric history.
Medical Health/Biological History: (Include illnesses, surgeries, and medications. Note any
current medical problems, physical disabilities, and/or eating disorders. Include development
throughout the life span and include any areas of concern.)
No physical disabilities or eating disorder were reported. Devin’s birth and developmental
history were uneventful according to the report. His mother reported that she had a full-term
pregnancy and Devin was born via vaginal delivery with no reported complications. H e sat up
took his first steps and was toilet trained at developmentally appropriate times. He has no
current health problems and takes no medication. His mother reports no known allergies His
past medical history did not include any hospitalizations or chronic illness.
Allergies:
There was no report for allergy
Medications: (Include name of medication, dose, condition it is treating, and its effectiveness—
OTC and prescription.)
_______________________There was no report of client being on medication and no
condition for treatment.______________ ___________________________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
Mental Health/Psychiatric History:
Has client ever been treated for a psychiatric illness:
Yes
No
Please explain: (Include if client had been hospitalized, seen by a mental health professional,
what they were seen for, and how long they were seen.)
SECTION II
Psychosocial History and Cultural Identity
Current Life Situation: (Summarize present living arrangements and any current social
supports.)
Sexual Orientation:
Devan’s sexual orientation may not be fully revealed but him preferring girl clothes and wand
wanting to hang around girls only does not necessarily means that he is gay. He doesn’t do well
with boys so it could be his gender expression which is different from his sexuality.
Spiritual Beliefs:
The spiritual belief oh his parents and family are non-accepting of his identity as they are more
traditional and do not seem to veer from their belief. They are Baptiste and conservative
Christian views. The entire family attends Baptist church every Sunday and Wednesday and
Teresa teaches vacation bible school in the summer and is active in the women circle.
Family Influence: (How does the client’s/parent’s cultural identity influence the client’s
perceptions of the problem?)
Educational History: (Note highest level of schooling completed, school performance, peer
relationships, and learning problems.)
Devin has historically thrived in school, developed friendships easily and responsive to early
learning skills. He has performed in the top 25%nof his class. He is currently in the third grade
and in a regular classroom with all passing grades. It is reported that since Deven has entered
third grade, he has shown a decreased interest in age-appropriate male relationships. He has
been on the receiving end of some teasing, especially by male peers, and has cried to his
mother that he does not want to go to school. It is reported that his grades declined from A’
and B’s to B’s and C’s. He has no history of disciplinary problems at school and never been
suspended
Client Strengths:
1. Deven is courageous enough to be themselves even with the stereotypical male
gender roles being imposed
2. He is comfortable and sure of who he is
SECTION III
Summative Conceptualization: (This narrative section pulls all of the information together from
the biopsychosocial history, with a clinical opinion about what the primary issues are and what
should be done to address them. Also state potential referrals that are appropriate at this
time.)
Diagnostic Impression: (Identify whether the issue is part of age- and gender-appropriate
development or a sexual disorder, and use the DSM to justify your conclusion.
According to the DSM, Deven might be experiencing Gender Dysphoria in children, a marked
incongruence between one’s experienced/expressed gender and assign, as manifested by at
least six of the gender, of at least 6 months’ duration as manifested by at least six of the
following (one of which must Criterion A1) Deven has met all of criteria A1 through 8 as well as
criteria B and it has been like that for long over 6months.
Goals (Identify one of each.)
Short-Term Goal:
Help the client gain a basic understanding of how normal Devin is and how to support the child
without feeing embarrassed. There is an urgency for the parents to understanding how
damaging their opinions and beliefs about gender and identity is to their child. Clinician would
also help parents understand the correlation between his identity not being accepted and
school performance.
Long-Term Goal:
To help the family understand the biology and science involved in their child’s identity. To help
them to accept and normalize his development as a part of who the child is. Desist imposing
behaviors clothes and other typical mail attributes and allow Deven to simply be who they are.
Also, to help Deven feel accepted, confident and free to without judgment.
Technique/Intervention: (Propose one technique or intervention to support the client in
accomplishing the therapeutic goals.)
The intervention I would use would be Adlerian theory as one of its focuses is on the
discouraged child, From the report, it can be speculated that Deven is feeling discouraged; not
being able to just be himself/their selves freely. Not being encouraged to like what he likes and
be free.
Clinician/Counselor Signature: _______Georgette Josephs________Date: __01/18/2022_____
COU 645 Final Project Case Study
Devin is an 8-year-old natal male who is brought to counseling by his mother, Teresa. Devin’s parents
are Caucasian and their socioeconomic status is middle class. Devin’s father, Richard, has always been
the primary financial provider. Teresa and Richard have been married for 14 years and also have two
younger daughters, ages 6 and 4.
Devin was born and raised in the southeastern United States. He was raised by his two biological
parents. His paternal grandparents are both alive and live in California, which prohibits frequent visits.
Devin’s maternal grandfather died when he was an infant, and his maternal grandmother lives nearby.
His grandmother visits frequently, babysits on a regular basis, and advises Teresa on parenting matters
Thus, the primary adult influences in Devin’s life are his parents and his maternal grandmother.
Devin’s parents have been together since high school and neither have had any other marriages or
significant intimate relationships other than with each other. Teresa describes them as “traditional,” and
the description of their marital relationship implies a patriarchal dynamic. Richard does not allow Teresa
to work outside of the home and has an expectation that she will keep a lovely home and raise
respectful children. Richard has a rigid parenting style and says that “the Bible and the belt” make the
rules in his house. Teresa has a more permissive parenting style and generally works to avoid conflict
with Richard at all costs. She presents as a loving parent who adores her children but yields to the
directives of her husband. Teresa worries about how strict Richard is, but defers to him in accordance
with their conservative Christian views. The entire family attends a Baptist church every Sunday and
Wednesday. Teresa teaches vacation bible school in the summer and is active in the “women’s circle.”
Teresa reports that she is bringing Devin to counseling because he shows a pervasive tendency to “do
things like a girl.” She also reports that when Devin is encouraged to participate in activities that are
stereotypically associated with boys, Devin becomes upset and may scream a refusal or withdraw and
sulk. These behaviors have occurred for as long as Teresa can remember, and both she and Richard are
worried that “something is wrong with him.” They tolerated his behavior at home and dismissed it as
something he would “grow out of” or associated it with having only female siblings to play with.
However, when church members began making comments about the behavior, Richard insisted that he
“get some help.” Teresa admits that she and Richard were both embarrassed by the comments and
snickering of fellow church members, and this propelled them to take action.
Devin’s birth and developmental history were uneventful. His mother reports she had a full-term
pregnancy and Devin was born via vaginal delivery with no reported complications. He sat up, took his
first steps, and was toilet trained at developmentally appropriate times. Devin has no current health
problems and takes no medication. His mother reports no known food or environmental allergies. His
past medical history did not include any hospitalizations or chronic illness.
He has historically thrived in school, developed friendships easily, and was responsive to early-learning
skills. He has performed academically in the top 25% of his class. He is currently in the third grade and in
a regular classroom with all passing grades. Since entering third grade, Devin has shown a decreased
interest in age-appropriate male relationships. He has been on the receiving end of some teasing,
especially by male peers, and has cried to his mother that he does not want to go to school. His grades
have declined from A’s and B’s to B’s and C’s. He has no history of disciplinary problems at school and
has never been suspended.
He attended a couple of counseling sessions with the school counselor when he was in second grade,
but he has not participated in any other counseling and has never had a medication evaluation. When
Teresa addressed her concerns with the pediatrician, the physician told her to “keep an eye on him.”
Teresa describes him as “effeminate, with manners and body movements more like a girl than a boy his
age.”
When asked for examples of Devin’s effeminate behavior, Teresa reports that he “tosses his hair like a
girl.” She emphasizes that he has never expressed interest in any contact sports or rough-and-tumble
play “like boys are supposed to.” According to Teresa, when he was about 4 years old, Devin would state
that he wanted to grow up to be a woman. He insists on sitting to urinate and refuses to wear boys’
underwear, preferring instead to wear his sisters’ panties. When his mother tries to insist, Devin reports
that he “doesn’t need a hole in the front.” Devin also refers to his penis as “disgusting.” He frequently
asks his mother if he can dress in her clothes, and he routinely plays dress up with his sister’s princess
costumes. He regularly wears a towel or a scarf on his head to simulate long hair. He enjoys putting on
makeup and playing dress up, and his fantasy play typically involves playing female figures such as
“mother.”
In terms of social relationships, Devin prefers to play with his sisters, though he will play with younger
male children during church youth activities. He struggles to relate to the boys in his class at school and
chooses to sit in the classroom at lunch with his female classmates. Devin is very affectionate toward his
mother and avoidant of his father. Devin especially likes going to visit is maternal grandmother who is
very loving and allows Devin to play freely as he chooses.
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Activities – COU-645-Q3187 Counseling Sexuality Issues 22TW3 – Southern New Hampshire University
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Reading List
23 points
17.25 points
O points
23 / 23
Client
Summary
Provides a summary of the client
Provides a summary of the client but lacks
detail or clarity
Does not provide a summary of the
client
ts
23 points
17.25 points
O points
23 / 23
Presenting
Problem
Explains how the client sees the
problem and the role of the client’s
identity in the presenting problem
Explains how the client sees the problem and
the role of the client’s identity in the
presenting problem but lacks detail or clarity
Does not explain how the client sees the
problem and the role of the client’s
identity in the presenting problem
ot
14 AM
23 points
17.25 points
O points
23 / 23
Family
History
pde-
Provides a complete family history
of the client
Provides a complete family history of the
client but lacks detail or clarity
Does not provide a complete family
history of the client
.docx
23 points
17.25 points
O points
Is
Biological
History
17.25 /
Provides a complete biological
history of the client
Provides a complete biological history of the
client but lacks detail or clarity
Does not provide a complete biological
history of the client
23
8 points
6 points
O points
8/8
Articulation
of Response
IS-
files
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Submission has major errors related to
citations, grammar, spelling, syntax, or
organization that negatively impact
readability and articulation of main ideas
Submission has critical errors related to
citations, grammar, spelling, syntax, or
organization that prevent understanding
of ideas
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