Biopsychosocial Intake Form

Biopsychosocial Intake Form Template for Canada

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Key Requirements PROMPT example:

"I need a Biopsychosocial Intake Form for my private psychology practice in Vancouver, with a focus on trauma-informed care and Indigenous cultural sensitivity, that complies with British Columbia's privacy laws and includes digital signature capability."

Document background

The Biopsychosocial Intake Form is a fundamental document used across Canadian healthcare settings to initiate patient care and assessment. It reflects the integrated approach to health assessment required by Canadian healthcare standards and privacy regulations. This document is typically used during a patient's first encounter with a healthcare provider or facility, gathering essential information across three primary domains: biological (medical history, current conditions), psychological (mental health, cognitive status), and social (family situation, support systems, cultural factors). The form ensures compliance with Canadian healthcare privacy laws while facilitating comprehensive patient assessment. It serves as a foundational document for treatment planning and continues to be referenced throughout the course of care.

Suggested Sections

1. Personal Information: Basic demographic information including name, date of birth, contact details, emergency contacts, and preferred language

2. Consent and Privacy: Information about confidentiality, privacy policies, and client consent for information collection and sharing

3. Current Concerns: Primary reasons for seeking help, current symptoms, and immediate concerns

4. Medical History: Current medical conditions, medications, allergies, past surgeries, and family medical history

5. Mental Health History: Previous mental health treatments, diagnoses, hospitalizations, and family mental health history

6. Social History: Family structure, living situation, education, employment, and social support systems

7. Risk Assessment: Current and historical risk factors including suicidal ideation, self-harm, and violence

8. Substance Use History: Current and past use of alcohol, drugs, and other substances

9. Treatment Goals: Client's objectives for treatment and desired outcomes

Optional Sections

1. Cultural Background: Information about cultural identity, beliefs, and practices that may influence treatment - included when working with diverse populations

2. Developmental History: Early childhood development, significant life events - particularly relevant for child/adolescent clients or trauma work

3. Legal History: Past or current legal issues - included when relevant to treatment or when working with forensic populations

4. Sexual History: Sexual health and relationship history - included when relevant to presenting concerns

5. Occupational Assessment: Detailed work history and occupational functioning - included when dealing with workplace issues or disability claims

6. Pain Assessment: Detailed pain evaluation - included when chronic pain is a presenting concern

7. Dietary Assessment: Eating patterns and nutritional concerns - included when eating disorders or health conditions are present

Suggested Schedules

1. Standardized Assessment Tools: Commonly used psychological assessment measures (e.g., PHQ-9, GAD-7, etc.)

2. Crisis Plan Template: Detailed safety planning document for high-risk clients

3. Release of Information Forms: Authorization forms for information sharing with other healthcare providers or third parties

4. Insurance Information: Details of insurance coverage and billing requirements

5. Service Agreement: Terms and conditions of service provision

6. Privacy Policy: Detailed explanation of privacy practices and information handling procedures

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 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

Social Services

Psychology

Psychiatry

Counseling Services

Rehabilitation Services

Primary Care

Occupational Health

Public Health

Private Practice

Relevant Teams

Clinical Operations

Mental Health Services

Primary Care

Patient Services

Medical Records

Quality Assurance

Healthcare Administration

Intake Processing

Behavioral Health

Clinical Assessment

Relevant Roles

Psychologist

Psychiatrist

Social Worker

Mental Health Counselor

Family Physician

Nurse Practitioner

Occupational Therapist

Clinical Director

Healthcare Administrator

Medical Office Manager

Intake Coordinator

Mental Health Therapist

Clinical Psychologist

Primary Care Physician

Rehabilitation Specialist

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