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Run: Biopsychosocial Assessment

Biopsychosocial Assessment template for behavioral health intake, capturing symptoms, psychiatric history, medical factors, substance use, and social context...

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Consent, Privacy, and Submission Notice

Consent to collect and use my health information for treatment and care coordination (required)

By checking this box, I acknowledge that the information I provide will be used for clinical assessment, treatment planning, and related care coordination.

Yes No N/A

I understand this form may include sensitive health information and will be handled according to applicable privacy policies (required)

Yes No N/A

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.

Yes No N/A

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 (required)

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 (required)

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? (required)

Prior treatment details

Known psychiatric diagnoses

In the past 2 weeks, have you had thoughts of harming yourself or ending your life? (required)

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? (required)

Immediate clinical follow-up needed

Yes No N/A

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

Get your results

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