Biopsychosocial Intake Form

Biopsychosocial Intake Form Template for Philippines

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Key Requirements PROMPT example:

"I need a Biopsychosocial Intake Form for my new mental health clinic opening in Manila in January 2025, with emphasis on cultural sensitivity and family dynamics, including sections in both English and Filipino languages, and compliance with the latest Philippine mental health regulations."

Document background

The Biopsychosocial Intake Form is a crucial document used in Philippine healthcare settings to establish a baseline understanding of a patient's overall health status and circumstances. This document is typically used during a patient's first interaction with a healthcare provider or facility, gathering comprehensive information across biological, psychological, and social domains. The form must comply with Philippine regulations, including the Mental Health Act of 2018 and Data Privacy Act of 2012, ensuring proper collection and protection of sensitive health information. It serves multiple purposes: establishing initial patient history, identifying immediate health concerns, assessing risk factors, and creating a foundation for treatment planning. The document is designed to be adaptable for various healthcare settings while maintaining consistency with Philippine healthcare documentation standards.

Suggested Sections

1. Client Information: Basic demographic information including name, date of birth, contact details, emergency contacts, and identification numbers

2. Presenting Problems: Current issues, symptoms, and concerns that brought the client to seek help

3. Medical History: Current medical conditions, past medical procedures, medications, allergies, and family medical history

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

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

6. Risk Assessment: Evaluation of current or historical risk factors including suicidal ideation, self-harm, and violence

7. Substance Use History: Current and past use of alcohol, tobacco, and other substances

8. Consent and Privacy Notice: Information about confidentiality, data privacy rights, and consent for treatment

Optional Sections

1. Cultural Assessment: Used when cultural factors are particularly relevant to treatment, including religious/spiritual beliefs and cultural practices

2. Developmental History: Added for child/adolescent clients or when developmental factors are significant

3. Military Service History: Included for veterans or active service members

4. Legal History: Added when legal issues are relevant to treatment or when required by court-ordered evaluations

5. Academic/School Information: Used for students or when educational factors are significant to treatment

6. Pain Assessment: Included when chronic pain or physical symptoms are part of presenting problems

Suggested Schedules

1. PHQ-9 Assessment: Standard depression screening questionnaire

2. GAD-7 Assessment: Standard anxiety screening questionnaire

3. Family Genogram: Visual representation of family relationships and medical/mental health history

4. Release of Information Forms: Standard forms for requesting or sharing information with other healthcare providers

5. Crisis Safety Plan: Template for developing safety strategies and emergency contacts

6. Treatment Agreement: Standard agreement outlining treatment expectations and policies

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 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

Medical Insurance

Primary Care

Psychiatric Services

Rehabilitation Services

Counseling Services

Educational Institutions

Corporate Wellness

Relevant Teams

Mental Health Services

Medical Records

Clinical Operations

Patient Intake

Quality Assurance

Compliance

Healthcare Administration

Patient Care

Behavioral Health

Risk Management

Relevant Roles

Psychiatrist

Clinical Psychologist

Licensed Social Worker

Mental Health Counselor

Primary Care Physician

Psychiatric Nurse

Healthcare Administrator

Medical Records Officer

Intake Coordinator

Clinical Director

Occupational Therapist

Case Manager

Wellness Coordinator

School Counselor

Employee Assistance Program Counselor

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Authors

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