Health Behavior Intervention Note (Group/Family HBAI)

Patient: [Name, MRN, DOB]
Date of Service: [Date]
Provider: [Name, credentials]
Encounter Type: [Group HBAI (2+ patients) / Family HBAI (patient present)]

Format-Specific Participant Information

(Complete only the section that matches the Encounter Type.)

Group HBAI (2+ patients)

• [Group or program name]
• [Session number, e.g., Session X of Y]
• [Patient attendance status]
• [Total group size]
• [Brief participation level descriptor for this patient] (Do not include names or identifiers of other group members.)

Family HBAI (patient present)

• Patient present for entire session: [Yes / No]
• [Family participant(s): first name or initials with relationship, e.g., Mother (J.S.), Spouse (A.)]
• [Brief statement establishing family member(s) active role in the care plan]

Medical Necessity

• Physical health condition: [Condition being addressed] [ICD-10 code if available] (If a linked physical health condition cannot be identified, do not complete as an HBAI note.)
• Biopsychosocial/behavioral factors: [1–2 sentence explanation of how behaviors, beliefs, symptoms, or environmental factors interfere with or enable management of the condition]

Goals (1–3 specific, measurable, time-linked goals tied to medical management)

• [Goal 1]
• [Goal 2] (Include only if applicable)
• [Goal 3] (Include only if applicable)

Interval Update (Include only for multi-session programs)

• [Adherence since last session]
• [Changes in symptoms or functioning relevant to the medical condition]
• [Barriers or facilitators encountered since last session]

Intervention Delivered

Session focus/module topic: [Topic]

Agenda items (2–5 items)

• [Agenda item 1]
• [Agenda item 2]
• [Agenda item 3]
• [Agenda item 4] (Include only if applicable)
• [Agenda item 5] (Include only if applicable)

Behavioral techniques/skills trained (Use clinically recognizable terms such as self-monitoring, stimulus control, activity pacing, relaxation training, cognitive restructuring of illness beliefs, problem-solving training, motivational interviewing strategies, or caregiver training in reinforcement plans; avoid education-only descriptions)

• [Technique 1]
• [Technique 2]
• [Technique 3] (Include only if applicable)

Individualization: [1–3 sentences explicitly linking today's content to this patient's specific targets and barriers] (Required for group format; for family format, include caregiver coaching or role in implementation if applicable)

Engagement & Response

Observed engagement: [Description with at least one concrete example, e.g., asked clarifying questions, completed in-session practice, generated personal triggers]

Participation level: [Active / Moderate / Minimal] (Group format only)

Family interaction pattern: [Brief note on patterns relevant to plan implementation] (Family format only; avoid unrelated family-therapy content)

Progress toward goals (Address each active goal; if not yet assessable, state why)

• [Goal 1: progress status and objective indicator]
• [Goal 2: progress status] (Include only if applicable)
• [Goal 3: progress status] (Include only if applicable)

Barriers identified today: [Behaviorally specific barriers]

Goal modifications: [Adjustments to targets, frequency, or criteria based on response] (Omit if none)

Plan

Homework/practice assignments (Include frequency and tracking method)

• [Assignment 1: frequency + tracking method]
• [Assignment 2] (Include only if applicable)

Family role assignments: [Who will do what, when, and how progress will be recorded] (Include only if applicable)

Follow-up: [Next session date or window]

Escalation criteria: [When to contact clinic/PCP or seek urgent care]

Safety (Include only if concerns arose during session)

• [Risk assessment summary]
• [Actions taken and referrals provided]

Face-to-Face Time: [Total minutes]
Start Time: [HH:MM] Stop Time: [HH:MM] (Include if required by policy)
Billing Code(s): [CPT code(s) and units] (Include only if required by workflow)

Signature: [Provider name, credentials]

Telehealth Appendix

(Include only if encounter was conducted via telehealth.)

• Modality: [Audio-video / Audio-only]
• Patient location: [Location at time of visit]
• Provider location: [Location]
• Telehealth consent obtained: [Yes / No]
• Emergency contact plan: [Plan if disconnected]