Biopsychosocial Intake Form Template for United States

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Key Requirements PROMPT example:

Biopsychosocial Intake Form

"I need a Biopsychosocial Intake Form for my new private mental health practice opening in March 2025, specifically designed for adolescent patients aged 13-17, with additional sections for parent/guardian input and school-related information."

Document background

The Biopsychosocial Intake Form is a fundamental document used across U.S. healthcare settings to initiate patient care and documentation. It represents a holistic approach to patient assessment, combining medical, psychological, and social elements to create a complete picture of a patient's health status and needs. This document is typically used during a patient's first interaction with a healthcare provider or practice, gathering comprehensive information that guides treatment planning and ensures compliance with HIPAA and other relevant healthcare regulations. The form serves as both a clinical tool and a legal document, establishing the foundation for the provider-patient relationship while collecting crucial information about medical history, current symptoms, social support systems, and psychological status.

Suggested Sections

1. Patient Information and Demographics: Basic identifying information, contact details, emergency contacts, and insurance information

2. Consent and Confidentiality Statement: HIPAA acknowledgment, informed consent for treatment, and explanation of confidentiality limits

3. Current Presenting Concerns: Primary reasons for seeking treatment, current symptoms, and their duration and severity

4. Mental Health History: Previous mental health treatment, hospitalizations, medications, and family mental health history

5. Medical History: Current medical conditions, medications, allergies, previous hospitalizations, and family medical history

6. Substance Use Assessment: Current and past substance use, including alcohol, drugs, and nicotine

7. Social History: Family background, living situation, education, employment, and significant relationships

8. Risk Assessment: Evaluation of suicide risk, self-harm, and violence risk factors

9. Current Functioning: Daily activities, self-care, work/school performance, and social relationships

10. Treatment Goals: Patient's objectives for treatment and desired outcomes

Optional Sections

1. Trauma History: Detailed assessment of past trauma experiences, used when trauma is identified as a contributing factor

2. Cultural Assessment: Evaluation of cultural factors affecting treatment, important for culturally sensitive care

3. Spiritual/Religious Assessment: Assessment of spiritual beliefs and their role in treatment, when relevant to patient care

4. Military Service History: Details of military service and related experiences, used for veteran patients

5. Pain Assessment: Detailed pain evaluation for patients with chronic pain conditions

6. Educational/Developmental History: Detailed developmental milestones and educational history, particularly relevant for younger patients

7. Legal History: Past legal issues and current legal situations affecting treatment

8. Sexual History: Assessment of sexual health and concerns when relevant to treatment

Suggested Schedules

1. PHQ-9 Depression Screening: Standardized depression screening questionnaire

2. GAD-7 Anxiety Screening: Standardized anxiety screening questionnaire

3. Safety Plan Template: Structured plan for managing crisis situations

4. Release of Information Forms: Standard forms for authorizing information sharing with other providers

5. Treatment Agreement: Detailed agreement outlining treatment expectations and responsibilities

6. Insurance Information Forms: Detailed insurance and payment information forms

7. Privacy Practice Notice: Detailed HIPAA privacy practices and patient rights

8. Crisis Resources List: Local and national crisis intervention resources

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Mental Health Services

Medical Practices

Psychology Services

Social Services

Psychiatric Services

Behavioral Health

Addiction Treatment

Rehabilitation Services

Integrated Healthcare

Relevant Teams

Clinical Operations

Mental Health Services

Patient Intake

Medical Records

Compliance

Quality Assurance

Administrative Services

Patient Care

Behavioral Health

Care Coordination

Relevant Roles

Clinical Psychologist

Psychiatrist

Licensed Clinical Social Worker

Mental Health Counselor

Primary Care Physician

Nurse Practitioner

Healthcare Administrator

Medical Records Manager

Intake Coordinator

Behavioral Health Specialist

Case Manager

Practice Manager

Compliance Officer

Quality Assurance Specialist

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Electronic Intake Forms

Legal framework for electronic intake forms compliant with US federal and state regulations, governing digital information collection and processing.

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Authors

Alex Denne

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