Biopsychosocial Intake Assessment (Child/Adolescent)

Date/Time: [Date and time of encounter]

Location/Setting: [outpatient / inpatient / ED]

Modality: [in-person / telehealth]

Visit Type: [initial intake / transfer of care / re-evaluation]

Interpreter: [Language and interpreter details] (Include only if interpreter was used.)

Data Completeness: [Complete / Partial—specify what remains pending]

Participants and Consent

(Use clear attribution throughout note, e.g., "Per mother...", "Per patient...". Differentiate between "Denied" (asked and denied), "Unknown" (asked but informant does not know), and "Not assessed" (not asked). Quote verbatim when clinically or legally salient. Do not infer high-stakes facts—custody/legal authority, abuse/neglect, medication adherence, access to lethal means, and consent status must be explicitly documented or marked Unknown/Not assessed.)

• Present: [Patient and accompanying adults with names and relationships; collateral participants if any]
• Confidential interview segments: [Whether separate caregiver-only and youth-only segments occurred]
• Legal guardian(s): [Names and basis for guardianship; who provided permission for today's evaluation] (If custody is unclear, state that legal custody was not verified, summarize caregiver report, and note plan to verify.)
• Confidentiality review: [Confirmation that confidentiality and its limits were reviewed in developmentally appropriate language]
• Adolescent information sharing: [What information may or may not be shared with caregivers; what was disclosed today after private interview] (Include for adolescents only.)

Referral and Chief Concern

Referral source: [Source and reason for referral]

Chief Concern (Caregiver): [Caregiver-stated concern in their own words]

Chief Concern (Patient): [Youth-stated concern in their own words] (If caregiver and youth goals differ, document both.)

Sources of Information

• Informants: [Patient, caregivers, others present] (Note reliability and any discordance between accounts.)
• Records reviewed: [Prior psychiatric/medical records, IEP/504, school reports, testing with dates]
• Standardized measures: [Measures administered with results, or note if pending]

History of Present Illness

[Narrative description of chief concern, timeline of onset, precipitating events, course (episodic vs chronic), and severity. Include relevant symptom domains: mood, anxiety, trauma symptoms, attention/executive function, behavior/oppositionality, sleep, appetite, psychosis-spectrum symptoms, and somatic complaints as applicable. Attribute statements to informants throughout.]

[Functional impairment across settings: home, school attendance and performance, peer and family relationships, self-care, activities]

[Coping strategies tried by youth and caregivers; what has helped]

[Strengths and interests observed or reported]

Safety and Risk Assessment

(Use explicit Present/Absent/Unknown notation with timeframe and informant attribution. Quote verbatim for salient statements.)

• Suicide risk and self-harm
  • Current suicidal ideation: [Present / Absent / Unknown] — [Frequency, intensity, timeframe, per informant]
  • Intent: [Present / Absent / Unknown]
  • Plan: [Present / Absent / Unknown] — [Details if present]
  • Access to means: [Present / Absent / Unknown] — [Firearms, medications, sharps; storage details]
  • Preparatory behaviors: [Present / Absent / Unknown]
  • Past suicide attempts: [Present / Absent / Unknown] — [Method, date(s), lethality, triggers]
  • Non-suicidal self-injury: [Present / Absent / Unknown] — [Method, frequency, function]
  • Safety planning and lethal means counseling: [Completed / Initiated / Declined / Not assessed]
• Homicidality and aggression
  • Threats toward others: [Present / Absent / Unknown] — [Intent/plan, targets, timeframe]
  • Access to weapons: [Present / Absent / Unknown]
  • History of violence/aggression: [Present / Absent / Unknown] — [Triggers, escalation/de-escalation patterns]
• Abuse/neglect/exploitation screening
  • Concerns disclosed or suspected: [Present / Absent / Unknown] (Document minimal necessary details.)
  • Immediate safety steps: [Taken / Recommended / Not indicated]
  • Mandated reporting: [Report filed / Pending / Not indicated] — [Agency, date, reference number if filed]
• Additional risks (Include as applicable.)
  • Elopement/runaway risk: [Present / Absent / Unknown]
  • Online exploitation risk: [Present / Absent / Unknown]
  • Substance intoxication risk: [Present / Absent / Unknown]
  • High-risk sexual behavior: [Present / Absent / Unknown] (Adolescents only.)
• Protective factors
  • [Reasons for living and future orientation]
  • [Supportive relationships and supervision quality]
  • [Engagement in care]
  • [Restricted access to means]
  • [Cultural, religious, or community factors]

Risk Summary: [Acute risk level] / [Chronic risk level] — [Synthesis of key risk and protective factors with rationale; risk mitigation plan for today]

Past Psychiatric History

• Prior diagnoses: [Diagnoses with approximate dates and diagnosing provider]
• Psychotherapy: [Type, duration, response]
• Medication trials: [Medication, dose, duration, benefit, adverse effects, adherence]
• Higher levels of care: [Hospitalizations, ED visits, PHP, IOP, residential with dates, reasons, outcomes]
• Psychological/neuropsychological testing: [Type, dates, key findings]
• Prior safety crises: [Events and management]

(If no prior psychiatric history, state explicitly.)

Medical History

• Medical conditions: [Chronic and acute conditions]
• Neurologic history: [Seizures, headaches, concussion/TBI, sleep disorders]
• Current medications: [Name, dose, indication] — [Adherence narrative if relevant]
• Allergies: [Medications and other allergies with reaction type]
• PCP: [Name, clinic]
• Recent vitals/labs: [If available and relevant]
• Substance exposures: [Caffeine/energy drinks, nicotine/vaping, cannabis, other] (Adolescents.)

Developmental History

(Include for children 12 and under; for adolescents, include if developmental concerns are relevant.)

• Prenatal/perinatal: [Complications, substance exposures, prematurity]
• Early milestones: [Speech/language, motor development]
• Early social development: [Social reciprocity, play patterns]
• Sensory and temperament: [Sensory sensitivities, temperament]
• Neurodevelopmental concerns: [Autism-related patterns, ADHD symptoms, learning difficulties]
• Prior services/evaluations: [Early Intervention, speech/OT/PT, developmental assessments]

Family and Caregiver Context

• Household composition: [Members and primary caregivers]
• Custody and recent changes: [Custody schedule if applicable; recent moves, separations, placements]
• Family dynamics: [Parenting approaches, discipline, routines, conflict patterns]
• Caregiver perspective: [Caregiver's formulation of the problem, what they have tried, hopes and concerns]
• Caregiver factors: [Stressors or health concerns affecting caregiving capacity]
• Family psychiatric history: [First-degree relatives: mood disorders, anxiety, ADHD, ASD, psychosis, substance use, suicide]
• Social determinants: [Housing stability, food security, transportation, insurance]

School Functioning

• Current school/grade: [School name, grade level]
• Attendance: [Attendance and tardiness patterns]
• Academic performance: [Strengths and concerns]
• Behavior at school: [Referrals, suspensions, peer conflict, bullying/victimization]
• IEP/504 status: [Services, accommodations, goals]
• School strengths: [Favorite classes, supportive staff, activities]
• School collaboration plan: [Planned contacts, ROI status, pending requests]

Social and Peer Functioning

• Friendships: [Quality, in-person vs online, social isolation]
• Activities and interests: [Clubs, sports, hobbies, strengths]
• Identity: [Gender identity and sexual orientation if clinically relevant; use affirmed name/pronouns]
• Adolescent confidential topics: [HEEADSSS domains as applicable] (Adolescents only; document in confidential manner.)
• Substance use screening: [Tool used, results]

Trauma and Adversity

(Document with minimal necessary detail in trauma-informed manner.)

• Types of trauma/adversity: [Violence exposure, abuse/neglect, medical trauma, bereavement, placements, discrimination]
• Current safety status: [Ongoing exposure, contact with perpetrator, protective actions in place]
• Trauma symptoms and triggers: [Current symptoms and known triggers]
• Readiness and boundaries: [Patient's readiness to discuss; boundaries set]

Mental Status Examination

• Appearance: [Description]
• Behavior/psychomotor: [Activity level, movements]
• Eye contact: [Description]
• Rapport: [Engagement and cooperation]
• Speech: [Rate, volume, articulation]
• Mood: "[Patient's words]"
• Affect: [Range, reactivity, congruence]
• Thought process: [Linear / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [SI/HI/obsessions/delusions: Present or Absent]
• Perceptions: [Hallucinations: Present or Absent; describe if present]
• Orientation: [Person / place / time / situation]
• Attention: [Description]
• Memory: [Immediate / short-term / long-term]
• Insight: [Description]
• Judgment: [Description]
• Developmental observations: [Play themes, separation from caregiver, frustration tolerance, emotion labeling, response to limits] (Younger children.)

Formulation and Diagnostic Impression

Working Diagnoses: [Diagnosis 1 (provisional if criteria not fully met)]; [Diagnosis 2]; [Differential diagnoses]

Biopsychosocial Formulation: [Narrative integrating predisposing factors (genetics, temperament, early adversity), precipitating factors (recent stressors), perpetuating factors (reinforcement cycles, avoidance, sleep disruption), and protective factors (supports, strengths). Connect explicitly to treatment plan.]

Level of Care: [Recommendation with rationale if other than standard outpatient] (Include only if higher level of care indicated.)

Plan

(Prioritize by severity and safety.)

• Safety/Crisis Plan: [Warning signs, coping strategies, supportive contacts, crisis resources, ED instructions, means restriction, supervision plan, follow-up interval] (Include for any meaningful safety risk.)
• Psychotherapy: [Modality linked to targets (CBT, TF-CBT, DBT skills, family therapy, parent management training); frequency; goals]
• Medication: [Medication initiated or considered with rationale; risks/benefits discussed; monitoring plan] (If deferred, document reason and information needed.)
• School/systems interventions: [Planned contacts, ROI status, evaluation requests, IEP/504 review, attendance planning]
• Referrals and workup: [Psychological testing, developmental evaluations, specialty referrals, labs] (Distinguish ordered vs recommended.)
• Follow-up: [Next appointment timeframe, who will attend, tasks to complete before then]

Pending Collateral

[Outstanding collateral information to obtain with responsible party and timeline] (Omit section if nothing pending.)