Biopsychosocial Assessment

Behavioral health intake form to document the presenting problem, psychiatric, medical, substance use, social, and developmental history, and to establish the clinical foundation for the treatment plan.

Consent, Privacy, and Submission Notice

• Consent to collect and use my health information for treatment and care coordination
  By checking this box, I acknowledge that the information I provide will be used for clinical assessment, treatment planning, and related care coordination.
• I understand this form may include sensitive health information and will be handled according to applicable privacy policies
• Submit anonymously where permitted
  If anonymous submission is enabled by your organization, you may choose to withhold identifying information. Note: anonymous submission may limit clinical follow-up.
• What happens after I submit
  A clinician or intake coordinator will review your responses, may contact you for clarification, and will use this information to support diagnosis, risk review, and treatment planning.

Client Identification and Referral Details

• Full name
• Date of birth
  Collect only if needed for clinical identification or age-based care requirements.
• Preferred name
• Pronouns
• Referral source
• Referral details

Presenting Problem and Current Symptoms

• Presenting problem
  Describe the main concern in the client's own words when possible.
• When did the current concern begin?
• Approximate duration of symptoms
• Current symptom severity
• How are these concerns affecting daily functioning?

Psychiatric History and Risk Screening

• Have you received prior mental health treatment?
• Prior treatment details
• Known psychiatric diagnoses
• In the past 2 weeks, have you had thoughts of harming yourself or ending your life?
• Self-harm or suicide risk details
  If yes, describe thoughts, intent, plan, means, and any protective factors.
• In the past 2 weeks, have you had thoughts of harming someone else?
• Immediate clinical follow-up needed

Medical, Substance Use, and Medications

• Relevant medical conditions
• Current medications
  List only medications relevant to care, including psychiatric medications if applicable.
• Any concerns taking medications as prescribed?
• Substance use in the past 12 months
• Substance use details
  Include frequency, amount, last use, and any impact on health or functioning.

Social, Family, and Developmental History

• Current living situation
• Support system
• Employment or education status
• Developmental history
  Include early developmental milestones, learning concerns, or childhood behavioral history if relevant.
• Trauma history
  Provide only information relevant to current care. Avoid unnecessary detail.

Clinical Summary and Initial Plan

• Clinician summary
  Summarize key biopsychosocial factors, strengths, risks, and clinical impressions.
• Initial treatment focus
• Follow-up needed