Biopsychosocial assessment template, with an intake example
Used by: Psychiatrists, therapists, social workers and primary care clinicians at intake.
A biopsychosocial assessment looks at a presenting problem through three lenses: the biological (health, medications, substances), the psychological (symptoms, history, thinking and coping) and the social (relationships, work, housing, culture). It is the usual intake note in behavioral health and the basis for the treatment plan.
The template, section by section
Presenting problem
Why the person is seeking care now, in their words, and the history of the concern.
- Reason for referral or visit
- History of the presenting problem
- Goals for treatment
Biological
Medical conditions, medications, sleep, appetite, substance use and family psychiatric history.
- Medical history and medications
- Sleep and appetite
- Substance use
- Family psychiatric history
Psychological
Current symptoms, psychiatric history, trauma, mental status and strengths.
- Current symptoms
- Prior diagnoses and treatment
- Trauma history
- Mental status examination
- Coping and strengths
Social
Relationships, supports, work or school, finances, housing, legal and cultural factors.
- Family and relationships
- Work, school and finances
- Housing
- Legal history
- Culture, faith and identity
Risk
Suicide, self-harm, violence and safety.
- Ideation, intent, plan, history
- Access to means
- Protective factors
Summary and recommendations
A formulation that ties the domains together, a working diagnosis and the recommended plan.
- Formulation
- Working diagnosis
- Recommendations and goals
Biopsychosocial assessment example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Presenting problem
32-year-old referred by primary care for worry and poor sleep for 8 months since starting a new role as a charge nurse. "I can’t turn my brain off." Goals: sleep through the night and stop dreading work.
Biological
Asthma, well controlled on an inhaled steroid. No other medications. Sleeps 4 to 5 hours with trouble falling asleep. Appetite unchanged. Two to three glasses of wine most evenings "to relax," up from occasional use a year ago. No tobacco or other substances. Mother treated for anxiety.
Psychological
Daily worry about work errors, muscle tension, irritability, and difficulty concentrating. No panic attacks. One episode of depression in college treated with counseling. No trauma history disclosed. Mental status: well groomed, cooperative, anxious affect, linear thought process, no perceptual disturbances, good insight. Strengths: conscientious, insightful, motivated.
Social
Lives with partner, supportive relationship. Works 12-hour shifts; recently promoted. Financially stable. No legal history. Runs occasionally, less in recent months.
Risk
Denies suicidal ideation now or in the past, self-harm and homicidal ideation. No firearms at home. Protective factors: partner, career, future plans.
Summary
Symptoms consistent with generalized anxiety disorder, maintained by a high-demand role, reduced exercise and increasing evening alcohol use, which is also worsening sleep. GAD-7 16. Recommendations: weekly CBT for anxiety with a CBT-I component for sleep, reduce alcohol (discussed its effect on sleep), resume exercise, and coordinate with primary care regarding medication options.
Tips from practice
- Write a formulation, not three lists. The value is in how the domains explain each other.
- Ask about alcohol quantity specifically; it often maintains anxiety and insomnia.
- Document risk assessment even when negative.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
Questions
- What are the three parts of a biopsychosocial assessment?
- Biological, psychological and social factors that bear on the presenting problem, followed by a formulation and recommendations.
- How long does a biopsychosocial assessment take?
- Usually one intake session, sometimes two. The written assessment summarizes what is relevant rather than recording every answer.
- Can an AI scribe write a biopsychosocial assessment from an intake?
- Yes. Scribeable can write intake assessments from a recorded session using a behavioral health template, which you review and sign.
Reviewed 2026-11-08.