Integrated Primary Care Behavioral Health Consultation Note (Older Adult)

Date/Time of Service: [Date and time]

Setting: [Clinic location]; [in-person / telehealth]

Requesting Clinician: [Name and role/title]

Behavioral Health Clinician: [Name and credentials]

Participants Present: [Patient]; [Caregiver name(s) and relationship(s) if present]; [Interpreter language if used]

Primary Language: [Primary language]

Consultation Type: [same-day warm handoff / scheduled follow-up / short-interval consultation]

Referral Question & Consultation Scope

[Referral question from requesting clinician] (Use verbatim wording when possible.)

• [Immediate trigger for referral]
• [Scope of this consultation] (State what this consultation will and will not cover.)

Consent & Information Sources

• [Consent to behavioral health consultation and information-sharing within the integrated team] (Include caregiver involvement consent when applicable.)
• [Information sources: patient interview / caregiver report / chart review / clinician report]
• [Reliability statement] (Note any limitations due to hearing, memory, language, or other factors.)

Presenting Concerns

[Chief concern in patient's words]. [Focused narrative answering the referral question] (Include timeline, functional impact, safety/adherence or caregiver burden, what has been tried, and patient priorities. Avoid exhaustive symptom lists.)

• [Onset, course, triggers, and current severity]
• [Functional impact on ADLs/IADLs]
• [Safety considerations or adherence concerns]
• [Prior strategies, medications, or therapies tried and response]
• [Patient priorities and goals]

Medical & Geriatric Context

• [Relevant medical conditions affecting mood, cognition, sleep, or pain]
• [Potential medication contributors] (Use "potential contributors" language; avoid implying causation.)
• [Sensory or communication factors]
• [Recent life transitions relevant to current concerns]

(Include only items directly relevant to the consultation; omit section if already documented elsewhere and not pertinent.)

Psychosocial & Functional Assessment

• Living situation: [Living arrangement and housing stability / Not assessed]
• Supports & caregiver strain: [Support network and caregiver burden level / Not assessed]
• ADLs: [Independent / needs assistance with specific activities / Not assessed]
• IADLs: [Medication management, finances, transportation status / Not assessed]
• Mobility/falls: [Mobility aids and recent falls or concerns / Not assessed]
• Safety considerations: [Means access, wandering risk, driving concerns, exploitation vulnerability / Not assessed] (Include means access only if risk-relevant.)
• Social determinants impacting plan: [Isolation, transportation, cost, food/housing, digital access / Not assessed]

(This section may be minimal when the consult is narrowly focused and function is stable; expand when cognition, self-management, safety, or unexplained decline is involved.)

Mental Status Examination

• Appearance/behavior: [Observation]
• Speech: [Rate, volume, fluency]
• Mood/Affect: [Stated mood]; [Affect range, reactivity, congruence]
• Thought process/content: [Organization and coherence]; [Abnormal content if present]
• Orientation/attention/memory: [Brief observations as noted during interview]
• Insight/Judgment: [Brief statement]
• Engagement: [Participation and rapport]

(Do not infer neurocognitive diagnoses from brief observation. If indicated, document "concern for cognitive impairment" and recommend formal assessment.)

Screening Measures

[Tool name, score, date, interpretation, and administration limitations] (Include only if tools were administered or referenced. If a prior tool was reviewed but not re-administered, state that. Omit this subsection entirely if no screening tools apply.)

Risk Assessment

[Brief safety screen statement] (For most consults: document presence or absence of suicidal and homicidal ideation. If not assessed, explain why and plan to assess at follow-up.)

(If any concern is present, expand to include the following:)

• [Suicidal ideation details: frequency and intensity]
• [Intent, plan, and means access]
• [Past attempts or self-harm; acute stressors]
• [Protective factors and reasons for living]
• [Self-neglect or abuse/exploitation concerns]
• [Clinical judgment: acute vs chronic risk with rationale]
• [Safety plan elements: coping strategies, support contacts, crisis resources, means safety steps, follow-up timing]
• [Disposition statement]

Clinical Formulation

[Integrated working formulation] (Summarize precipitating factors, perpetuating factors, protective factors, medical contributors, and functional consequences in one concise paragraph.)

• Working diagnoses: [Diagnoses or differentials] (Use "working diagnosis" or "symptoms consistent with" when certainty is limited; for cognitive concerns use "memory concerns requiring further evaluation.")
• Functional impact: [Summary of functional consequences]

Interventions Provided

• [Interventions delivered] (e.g., psychoeducation, motivational interviewing, behavioral activation, CBT-I elements, relaxation, problem-solving, caregiver coaching, adherence planning)
• [Patient response, engagement, and barriers raised]
• [Teach-back or demonstration used]
• [Materials provided]

(If no intervention beyond assessment, state reason.)

Health Behavior Targets & Goals

(Identify 1–3 target behaviors with specific, measurable, realistic goals appropriate for older adults.)

• Target: [Behavioral or health target]

  Goal: [Specific, measurable goal]

  Barrier(s): [Barriers and coordination needs]

  Self-management plan: [Concrete steps patient/caregiver will take before next contact]

Recommendations & Plan

(Organize by problem or target. State medical recommendations as "recommend PCP consider" rather than orders.)

• Problem/Target: [Brief statement]
• Recommendations: [Behavioral steps and education]; [Medical recommendations for PCP consideration]
• Responsible party: [Patient / PCP / BHC / caregiver / care manager]
• Timeframe: [Specific interval or date]
• Follow-up metric: [Measure to review at next contact]

[Required safety actions if applicable: means safety, driving evaluation referral, mandated reporting with actions taken]

Care Coordination

• [Warm handoff details and real-time communication with requesting clinician]
• [Referrals placed or messages sent]
• [Information shared with caregivers and scope of permission]
• [External coordination with consent noted]

Follow-Up & Disposition

• Follow-up type: [None / PRN / BHC follow-up / PCP follow-up only]
• Timing: [Specific interval]
• Monitoring plan: [Symptom or goal metric to review]
• Escalation criteria: [Worsening risk indicators and actions to take]