Integrated Primary Care Behavioral Health Warm-Handoff Consultation Note

Date of Service: [Date]

Time: [Start time–End time / Total encounter minutes]

Location: [Clinic location]

Modality: [in-person / video / phone]

Patient Present: [Yes / No]

Support Person Present: [Name and relationship] (Omit line if none present.)

Interpreter: [Language and interpreter ID] (Omit line if not used.)

Referring Clinician: [Name, credentials]

Behavioral Health Clinician: [Name, credentials]

Consent: Patient informed of IPCBH role, brief nature of service, and team-based communication; consented to consult and coordination with primary care team. [Scope limitations for sensitive information, if applicable]

Reason for Consult

[Referral question, clinical context prompting warm handoff, and patient's stated goal] (Write 2–4 sentences. Include patient's words for their goal only when it adds clarity.)

Focused Assessment

[Narrative assessment of presenting problem] (3–8 sentences addressing: onset, duration, and course; key triggers and relevant medical/medication context; severity and functional impact on work, school, caregiving, sleep, or treatment adherence; prior episodes and what has helped; current supports, barriers, and strengths. Include relevant prior mental health treatment, current psychotropic medications and adherence, substance use if relevant, and social determinants affecting the plan. Include only elements that materially affect assessment, risk, or plan. Note "Not assessed" with brief reason if an expected element was not obtained.)

[Screening tool name: score (severity descriptor), date] (List each validated screening tool on its own line. Omit entirely if no tools administered.)

[Behavioral observations: appearance, orientation, mood/affect, thought process/content, engagement] (Include only when needed for clinical clarity. Use objective descriptors.)

Risk Assessment

(Include this section only if clinically indicated—positive screen item, expressed ideation, severe depression, intoxication/withdrawal, psychosis, mania, IPV/abuse concerns, or required by policy. Omit entirely if not indicated.)

• Suicidal ideation: [none / passive / active]; Plan: [Yes / No]; Intent: [Yes / No]; [Past self-harm or attempts if relevant]
• Homicidal ideation: [None / Present] (Include only if indicated.)
• Acute concerns: [Agitation / Intoxication / Withdrawal / Psychosis / Mania / Command hallucinations] (Include only if present.)
• Protective factors: [Relationships, beliefs, responsibilities, reasons for living]
• Access to lethal means: [Description]; Means safety counseling: [Yes / No]; [Details if provided]
• Overall risk level: [low / moderate / high]; [1–2 sentence rationale]
• Risk mitigation actions today: [Actions taken]
• Safety plan summary: [Warning signs, coping strategies, social supports, professional resources/crisis line, means safety steps, follow-up timing and responsible party] (Include only if safety planning performed.)

Clinical Impression

[Problem-focused working formulation in functional and contextual terms appropriate for primary care] (1–3 sentences. Include formal diagnoses only if required by clinic policy or billing. Note differential considerations only if they affect immediate triage or medication safety.)

Intervention Provided

Intervention type(s): [Psychoeducation / Brief CBT skill / Motivational interviewing / Relaxation technique / Problem-solving / Values clarification / Resource navigation]

• [Key content or skill taught]
• [Key content or skill taught]
• [Key content or skill taught] (Include 1–3 bullets describing what was delivered.)

Patient response: [Description of engagement, in-session practice, and confidence/intent to use skills]

Coordination actions: [Real-time discussion with PCP, orders placed, referrals initiated] (Specify recipients and timing.)

Disposition and Plan

Disposition: [Managed in primary care with IPCBH follow-up / Referred to specialty outpatient therapy / Referred to psychiatry / Referred to substance treatment / Escalated to crisis pathway or ED]; [Brief rationale]

Follow-Up: [Behavioral health follow-up timing, modality, and responsible party; PCP follow-up timing; For referrals: destination, urgency, and who will schedule]

Patient Instructions:

• [Home practice item or skill]
• [Educational resources provided]
• [Crisis instructions if risk identified]

Team Tasks:

• [PCP responsibility]
• [BHC responsibility]
• [Patient responsibility]

Communication to Medical Team

Summary communicated: [Referral question answered, key findings affecting medical care including risk level, functional impairment, barriers, and recommendations]

Method and timing: [Discussed in real time / EHR message / Phone]; [Timing relative to visit]

Shared plan confirmation: [Confirmation that PCP, BHC, and patient agree on the plan]