Behavioral Health Diagnostic Evaluation or Biopsychosocial Intake

Patient: [Full name]  |  DOB: [Date of birth]  |  MRN: [Medical record number]

Date of Service: [Service date]  |  Start time: [Start time]  |  Stop time: [Stop time]

Setting: [in-person / telehealth audio-video / telehealth audio-only]  |  Patient Location: [Location] (Include if telehealth.)

Clinician: [Clinician name], [Credentials] — [Role/Discipline]

Participants: [List all present and roles (patient, family, interpreter, collateral, etc.)]

Encounter Type: Initial diagnostic evaluation / biopsychosocial intake (CPT 90791)

Attestation: Informed consent and limits of confidentiality reviewed; patient verbalized understanding.

Referral and Sources of Information

[Referral source] — [Reason for referral / clinical question] (e.g., diagnostic clarification, treatment planning, level-of-care determination.)

• Primary information sources: [Patient interview / Collateral contacts / Prior records reviewed] (Briefly note scope and dates.)
• Reliability and limitations: [Reliable / Partially reliable / Questionable] (Brief justification: guardedness, cognitive impairment, intoxication, inconsistent history, language barriers.)

Chief Concern and History of Present Illness

Patient-stated reason for visit: [Brief summary or short direct quote if clinically defining]

[Chronological narrative of current symptoms and course] (Include onset, duration, and course [worsening / improving / fluctuating]; triggers and context such as losses, conflicts, medical illness, trauma reminders; symptom characterization relevant to differential: mood, anxiety, trauma-related, psychosis, mania/hypomania, eating, attention/executive function, sleep, appetite; current severity and functional impact on work/school/relationships/self-care; prior coping attempts and what helped or did not; patient goals for treatment.)

Screening instruments: [Instrument name] — [Score] — [Severity band] — [Brief interpretation] (Omit if none administered.)

Psychiatric History

• Past diagnoses: [List with source: patient-reported vs records] (Include approximate dates when known.)
• Prior treatment: [Outpatient therapy types and response; IOP/PHP/residential; hospitalizations; ER/crisis visits; involuntary holds] (Include dates/counts when available.)
• Current psychiatric medications: [Medication, dose, schedule, adherence, benefit/side effects] (State Unknown if not available.)
• Past medication trials: [Agents tried, response, reasons discontinued]
• Suicide/self-harm history: [Approximate dates, methods, medical severity, intent]
• Violence/aggression history: [If relevant, include context and outcomes]
• Family psychiatric history: [Major mood, psychotic, suicide, substance use disorders in first-degree relatives if relevant]
• Deferred/not assessed: [Domains not assessed and plan to complete] (Include only if applicable.)

Medical History

• Major medical conditions: [Conditions relevant to mental health (e.g., thyroid disease, chronic pain, TBI, seizures, sleep apnea, pregnancy/postpartum)]
• Current non-psychiatric medications: [List with indications if relevant]
• Allergies/adverse reactions: [Medication/agent and reaction]
• PCP/medical care: [PCP name/clinic if known]
• Medical contributors to current symptoms: [Brief assessment if symptoms may be medically driven] (Include rationale and plans for medical evaluation if indicated.)

Substance Use History

(Quantify use; avoid vague descriptors.)

• Alcohol: [Quantity, frequency, pattern, last use]
• Cannabis: [Quantity, frequency, route, last use]
• Nicotine/tobacco: [Type, quantity, frequency]
• Caffeine/energy products: [Quantity, timing] (Include if anxiety/insomnia prominent.)
• Other substances: [Substance, quantity, frequency, route, last use]
• Prescription/OTC misuse: [Agents and pattern]
• Withdrawal history: [Symptoms and severity]  |  Overdose history: [Dates, circumstances]
• Treatment history: [Detox, MAT, rehab, counseling; response]
• Relationship to psychiatric symptoms: [Temporal associations, triggers, exacerbations]
• Patient declined to discuss: [Yes/No] (If Yes, document reason and plan to revisit.)

Trauma and Adverse Experiences

(Use trauma-informed, non-graphic documentation.)

• Trauma exposure: [Childhood adversity / IPV / sexual assault / combat / accidents / disasters / other] (Note timing and clinical relevance.)
• Current trauma-related symptoms and triggers: [Brief description]
• Current safety concerns: [Ongoing IPV / stalking / unsafe living situation / other] (Note any mandated reporting considerations.)
• Patient preferences for disclosure: [Prefers not to discuss specifics / agreeable to future exploration] (Document rationale and plan.)

Social History and Supports

• Living situation and household: [Residence type, household members]
• Relationships/family roles: [Status, caregiving responsibilities]
• Education/work: [Status, role, attendance/performance]
• Social supports/community: [Family, friends, community, faith, groups]
• Cultural/language needs: [Interpreter needs, cultural considerations]
• Social determinants impacting care: [Transportation / housing / food insecurity / financial strain / insurance barriers / legal issues] (Link barriers to treatment feasibility in plan.)

Strengths and Protective Factors

• Internal strengths: [Motivation, insight, coping skills, spirituality, reasons for living]
• External supports: [Family, community, employment, services]
• Application to care and risk mitigation: [How strengths will support treatment and safety]

Functional Assessment

[Summary of functional impairments and capacities] (Describe work/school attendance and performance, relationships, self-care/ADLs, sleep-wake schedule, executive functioning. Include concrete anchors such as missed days, task completion, conflicts. This section establishes medical necessity by linking symptoms to functional impact.)

Mental Status Exam

• Appearance and grooming: [Description]
• Behavior and psychomotor: [Calm / cooperative / agitated / slowed / restless / other]
• Speech: [Rate, volume, prosody, articulation]
• Mood (patient-reported): [Description]
• Affect (observed): [Range, intensity, congruence, stability]
• Thought process: [Logical / goal-directed / tangential / circumstantial / disorganized]
• Thought content: [Delusions / obsessions / preoccupations]  |  Suicidal ideation: [Present / Absent]  |  Homicidal ideation: [Present / Absent]
• Perceptions: [Hallucinations / illusions / none]
• Cognition: [Orientation, attention, memory] (As assessed.)
• Insight: [Good / fair / limited]
• Judgment: [Good / fair / limited]
• Impulse control: [Adequate / impaired]
• Limitations to exam: [Telehealth modality, language, intoxication, guardedness, other] (Include only if applicable.)

Risk Assessment

Suicide and Self-Harm Risk

• Current suicidal ideation: [Present / Absent / Unable to assess] (Specify how assessed.)
• If present: [Frequency, intensity, plan, intent, means access, timeframe]
• Past attempts/self-harm: [Approximate dates, methods, medical severity, intent]
• Acute risk factors: [Intoxication, recent loss, agitation, command hallucinations, hopelessness, etc.]
• Protective factors: [Supports, reasons for living, responsibilities, engagement in care]
• Lethal means counseling: [Firearms, medications, other means; counseling provided; actions taken for secure storage or removal]

Violence Risk

• Current violent/homicidal ideation: [Present / Absent / Unable to assess]
• If present: [Target, plan, intent, weapons access]
• History of violence/legal issues: [Brief summary and context]
• Protective factors and de-escalation capacity: [Brief summary]

Overall Risk Level and Mitigation Plan

• Overall suicide risk: [Low / Moderate / High] [Acute / Chronic] — [Brief clinical rationale]
• Overall violence risk: [Low / Moderate / High] — [Brief clinical rationale]
• Mitigation/safety plan: [Safety or crisis response plan discussed; emergency contacts; 988 and local crisis resources provided; lethal means restriction plan; higher level of care referral if indicated; follow-up interval; patient agreement with plan]
• Incomplete assessment: [If any component not completed, document reason and steps taken to ensure safety] (Include only if applicable.)

Diagnostic Impression

• Primary diagnosis: [ICD-10 code — Diagnosis name] [Provisional / Confirmed]
• Additional diagnoses: [ICD-10 code — Diagnosis name] (Include comorbid substance use and trauma-related diagnoses as supported.)
• Rule out: [Conditions to clarify and needed data]

Differential diagnosis: [Brief justification for alternatives considered and why less likely] (Include only when clinically meaningful.)

Formulation: [Concise biopsychosocial synthesis: predisposing factors, precipitating factors, perpetuating factors, protective factors; link to treatment implications. Use language such as "appears consistent with" or "may be contributing."]

Treatment Plan

(Prioritize safety, then major syndromes, then functional issues.)

[Problem 1]: [Target problem]

• Goals: [Observable, time-bounded goals]
• Planned interventions/modality: [CBT / DBT skills / trauma-focused therapy / behavioral activation / other] — [Frequency and duration]
• Referrals/coordination: [Psychiatry/medication management; higher level of care with rationale; PCP for medical evaluation; case management; social services]
• Safety plan and crisis resources: [Coping strategies; emergency contacts; 988; when to go to ED]
• Care coordination: [Planned collateral contacts and information to share] (Document consent and limits.)
• Patient engagement: [Agreement/disagreement; preferences; barriers and accommodations]

[Problem 2]: [Target problem]

• (Repeat elements above as applicable.)

Follow-up

• Recommended level of care: [Outpatient / IOP / PHP / Residential / Inpatient] (Provide brief rationale.)
• Next appointment: [Date/time or timeframe]
• Urgent instructions and warning signs: [What to monitor; when/how to seek urgent care]
• If patient declined recommended plan: [Document discussion, assessment of capacity, and alternative plan offered] (Include only if applicable.)

Documentation principles: Distinguish patient-reported information, clinician observation, and collateral/records. Use explicit states for missing information: Unknown, Not provided, Not assessed, Patient declined. Avoid psychotherapy process content or speculation. Use non-stigmatizing, behaviorally descriptive language.