Integrated Primary Care Behavioral Health Consultation Note (Pediatric)

Date: [Date of service]

Time: [Start time – End time] (Include only if required for billing)

Patient Name: [Patient full name]

DOB: [Date of birth]

Clinician: [Clinician name, credentials]

Referring PCP: [PCP name, credentials]

Service Type: [warm-handoff / same-day consult / scheduled BHC visit]

Location/Setting: [in-person / telehealth] (If telehealth, specify platform, patient physical location, and that consent for telehealth was obtained.)

Interpreter: [Language and mode] (Include only if interpreter used)

Consult Trigger & Referral Question

Trigger: [Trigger for consultation] (Briefly state what prompted today's consult: positive screen, caregiver concern, clinician concern, behavioral issue during visit, adherence concern, or somatic symptoms with suspected stress component.)

Referral question: [Specific decision support the primary care team needs today] (If unclear, document how it was clarified with PCP/caregiver or note limitations.)

Chief concern: "[Patient/caregiver words]" (Optional brief quote or paraphrase)

Participants & Information Sources

• Present for consult: [patient / parent-guardian / other caregiver(s)]
• Sources of information: [patient / caregiver / chart / PCP / school / other]
• Custody/consent context: [Relevant details] (Include only if it affects care today)
• Setting constraints: [e.g., brief hallway handoff, limited time, patient minimally verbal] (Include only if applicable)

Confidentiality & Assent

(Include this section for adolescents or when developmentally appropriate; omit for young children unless safety concerns exist.)

• [Confidentiality reviewed and limits explained (safety/mandatory reporting)]
• [Adolescent private time occurred / did not occur] (If not, document barrier)
• [Assent obtained; findings will be shared with the care team as part of integrated care]

Focused Assessment

Presenting Problem: [Onset, duration, course; current symptoms relevant to the referral; key triggers and maintaining factors; what helps/doesn't; goals for today] (3–6 sentences focused on same-day decision-making)

Functional Impact:

• School/Daycare: [attendance, performance, accommodations, disciplinary issues] (Include only if relevant)
• Home/Family: [routines, conflict, caregiver stress, family functioning] (Include only if relevant)
• Peers/Social: [peer interactions, isolation, bullying; social media for adolescents] (Include only if relevant)
• Sleep/Appetite/Activity: [concise summary] (Include only if relevant to severity)

Relevant History: [Prior behavioral health treatment; pertinent diagnoses in chart; current psychotropic medications with recent changes; salient family history; key psychosocial stressors] (Include selectively if it changes today's decisions. Note if history is limited by brief consult.)

Screening Measures

(Include this section only if screening instruments were used or triggered the consult; otherwise omit entirely.)

• [Instrument name]: [Reporter: patient / parent / both], [Date]; Score: [score]; Flagged items: [notable items, especially self-harm]; Interpretation: [per tool standards]; Clinical correlation: [one-line synthesis]
• (Add additional instruments as separate bullets if applicable)

Safety Assessment

(Include this section when any safety concern exists, a positive self-harm screening item is present, or clinical concern warrants assessment; otherwise omit.)

• Suicidal/self-harm ideation: [denied / present] (If present, document recency, frequency, plan, intent, access to means, past behavior; include non-suicidal self-injury if relevant.)
• Harm to others: [denied / present] (If present, describe threats, intent, targets, and access to weapons.)
• Abuse/neglect/trafficking concerns: [concerns present / not indicated] (If present, state whether a report was made.)
• Substance use: [screening findings] (Include for adolescents when clinically relevant.)
• Protective factors: [2–3 specific factors: caregiver supervision, reasons for living, future goals, engagement in care]
• Risk level: [low / moderate / high] based on [key factors]. Disposition rationale: [Why current level of care is appropriate].
• Limitations: [Information not assessed and why; collateral sources consulted; interim safety steps taken] (Include when information is incomplete or patient unable/unwilling to answer.)

Mental Status Observations

(Brief behavioral observations anchoring clinical impressions. Omit if patient not directly seen; if collateral-only consult, state that explicitly.)

• Appearance/behavior: [observations]
• Engagement/relatedness: [observations]
• Mood/affect: [observations]
• Speech/language: [observations]
• Thought process/content: [observations]
• Developmental appropriateness: [observations]

Clinical Impression

[Concise case formulation synthesizing presenting problem, likely contributing and maintaining factors (biopsychosocial), and protective factors.]

Working diagnosis: [provisional diagnosis / rule out(s) / symptom-focused statement] (Use provisional language when full criteria were not assessed; specify what remains unknown.)

Problem prioritization: [List prioritized problems, with any safety concerns first]

Intervention Delivered Today

• Intervention type(s): [psychoeducation / motivational interviewing / brief CBT skill / parent coaching / problem-solving / relaxation / sleep hygiene / crisis-safety planning / other]
• Target behavior/skill practiced: [description]
• Materials/resources provided: [handouts / websites / crisis numbers / coping plan / community resources]
• Patient/family response: [engagement, comprehension, readiness, barriers]
• Team integration actions: [returned to PCP to review plan / huddle with nursing / care manager coordination]

Triage Level & Disposition

[Level 1 – Emergent / Level 2 – Urgent (24–72h) / Level 3 – Routine BHC Follow-up / Level 4 – Self-Management + PCP Monitor]

• Rationale: [1–2 lines linking risk/need to level]
• Immediate next steps: [specific actions: emergency evaluation, crisis line, expedited referral, schedule BHC follow-up, provide resources]
• Responsibility & timing: [who will do what and by when]

Recommendations to Care Team

• Medical evaluation: [sleep, thyroid/anemia, medication side effects, pain/somatic workup] (Include only if indicated)
• Medication considerations: [monitoring, initiation, adjustment] (State if psychiatry referral is recommended)
• School coordination: [school counselor contact, accommodations, IEP/504 evaluation] (Include only if indicated)
• Care coordination: [referrals placed, social work, community resources] (Include only if indicated)

(If no additional recommendations beyond follow-up plan, state: "No additional recommendations beyond the follow-up plan.")

Recommendations to Patient/Family

• [Action step 1 in plain language] (Include barrier(s) discussed and mitigation strategy)
• [Action step 2 in plain language] (Include crisis instructions when relevant)
• Follow-up instructions: [how to schedule, what to do if symptoms worsen]

Follow-Up Plan

• BHC follow-up: [timeframe, modality, focus]
• PCP follow-up: [timeframe, focus]
• Interim team actions: [RN outreach, care manager call, school forms] (Include only if applicable)
• Contingency plan: [red flags and urgent contact instructions]
• Scheduling plan: [appointments scheduled / clinic to outreach if not scheduled]

Communication & Coordination

(Include when handoffs or external communication occurred; otherwise omit.)

• Results reviewed with: [PCP / RN / care manager]; patient/family [agreed / did not agree] to the plan
• External communications: [school / outside therapist / community agency]; consent/ROI [obtained / pending]

Time & Services

(Include only if required for billing or productivity tracking.)

• Total clinician time: [minutes]
• Face-to-face time: [minutes] (If required)
• Non-face-to-face/collateral time: [minutes] (If required)

Electronic Signature: [Clinician name, credentials] — [Date/time signed]