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Mental Health Therapist
15-20 minutes

BPS Assessment

The s10.ai Intake BPS template is an all-encompassing resource for psychotherapists to meticulously document a client's initial evaluation. This template addresses key areas such as presenting issues, current symptoms, functional impairments, and mental health history. It also incorporates sections on family history, psychosocial elements, and cultural considerations, offering a comprehensive perspective on the client's circumstances. Designed to enhance risk assessment and mental status examination, this template ensures the capture of all pertinent information for precise diagnosis. Mental health professionals looking to optimize their intake procedures and elevate client care will find this template indispensable.

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Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

History of Current Illness
Presenting Issues/Primary Complaint:
(Explain the reason the client is seeking treatment now, including the onset, duration, and severity of symptoms. Direct quotes from the client may be included.)
Current Symptoms:
(List and describe any symptoms, whether reported or observed.)
Functional Impairment Area(s):
(Answer how symptoms are specifically affecting the client's functioning in this area.)
History of Mental Health/Substance Use Treatment:
(Provide details of the client's history of mental health and substance use treatment. If no history is noted in transcripts, context, or notes, write "N/A.")
Family History of Mental Health/Substance Use, Including Treatment:
(Provide details of the client's family history of mental health and substance use, including any treatment. If no family history is noted in transcripts, context, or notes, write "N/A.")
Psychosocial:
(Document all social concerns such as educational, employment, legal, financial, and other issues.)
Interpersonal/Family Information:
(Describe any close relationships, including overall relationship qualities with friends and family, significant romantic/sexual relationships, coworkers, etc.)
Current Living Situation:
(Include details such as environmental conditions, risks of homelessness, who the client lives with, and any other relevant living situation information.)
Cultural Considerations:
(Document all information relevant to the client's culture. Include how the client's cultural or other identities impact their perceptions and understanding of their symptoms, help-seeking behavior, and engagement with mental health service providers.)
Trauma and/or Abuse History:
(Include details of all/any client's traumatic or abusive experiences. If no trauma is noted in transcripts, context, or notes, write "N/A.")
Client Strengths:
(Document client strengths such as character strengths, social strengths—e.g., support system, financial strengths—e.g., stability, or anything else that contributes to client potential and well-being.)
Substance Use
Current Substance Use:
(Note any identified substance use behavior in the client. Specify [Frequency of use], [Date of last use], [Age of first use], and any other details of current substance use. Write "N/A" if no substance use was mentioned anywhere in transcripts, context, or notes.)
Previous Substance Use:
(Document “None” or describe the details of previous substance use found in transcripts, context, or notes.)
Health History and/or Current Medical Conditions:
(Describe the details of past or current health conditions found in transcripts, context, or notes. If none exist, write "No relevant past or present health concerns reported.")
Current Medications:
(List all medications, including [Medication name], [Dose], [Reason Prescribed/Purpose] for each.)
Primary Care Physician: (Fill in specifics of [Physician Name], [Physician Phone Number], and [Last PCP Visit/Routine Exam] or document "None Reported" if the client does not see a PCP.)
Psychiatrist/NP: (Fill in specifics of [Psychiatrist Name], [Psychiatrist Phone Number], and [Last Psych Visit] or document "None Reported" if the client does not see a psychiatric practitioner.)
Risk Assessment
1. Columbia Suicide Severity Rating Scale (C-SSRS):
(Insert C-SSRS scores from any noted in context; otherwise, write "N/A.")
2. (Write a detailed account of any noted suicidality found in transcripts, context, or notes. If no suicidality exists past or present, write "Client denies any current or past suicidal ideation.")
MSE (Mental Status Exam)
(Describe the client's mental status under each of the following categories:)
1. Mood: (Include appropriate or relative descriptors such as: --Euthymic --Depressed --Anxious --Angry --Irritable --Euphoric --Other (Specify))
2. Appearance: (Include appropriate or relative descriptors such as: --Linear, goal-directed --Tangential --Circumstantial --Flight of Ideas --Other (Specify))
3. Thought Process: (Include appropriate or relative descriptors such as: --Well-groomed --Disheveled --Inappropriate --Other (Specify))
4. Rapport: (Include appropriate or relative descriptors such as: --Cooperative --Defensive --Hostile --Demanding --Distrustful --Other (Specify))
5. Thought Content/Perceptions: (Include appropriate or relative descriptors such as: --Normal --Ruminations --Suicidal Thoughts --Obsessions --Compulsions --Derealization --Re-experiencing --Hallucinations --Delusions --Other (Specify))
6. Behavior: (Include appropriate or relative descriptors such as: --Normal --Agitated --Restless --Impulsive --Slowed lethargic --Tics --Other (Specify))
7. Cognition: (Include appropriate or relative descriptors such as: --Normal, Fully Oriented --Derealization --Drowsy --Memory impairment --Attention Impairment --Other (Specify))
8. Speech: (Include appropriate or relative descriptors such as: --Normal --Rapid --Pressured --Slurred --Other (Specify))
9. Insight: (Include appropriate or relative descriptors such as: --Good --Fair --Poor --Other (Specify))
10. Affect: (Include appropriate or relative descriptors such as: --Appropriate --Constricted --Labile --Blunted --Flat --Other (Specify))
11. Judgment: (Include appropriate or relative descriptors such as: --Good --Fair --Poor --Other (Specify))
Clinical Summary
(Provide a summary of the clinical assessment, including details to justify the initial diagnosis for the client. Include ways in which the client's mental health symptoms are impairing their functioning in one or more areas of their life and why treatment is needed at this time.)
Diagnosis
(Provide diagnostic suggestions based on DSM-V-TR criteria.)
Sample Clinical Note

Example of completed documentation using this template

History of Present Illness
Presenting problems/chief complaint:  
The client, a 32-year-old female, is seeking treatment due to ongoing feelings of anxiety and depression that started about six months ago. She notes that the symptoms have intensified over the past two months, affecting her daily activities. "I feel overwhelmed and unable to cope," she states.
Current Symptoms:  
The client reports experiencing anxiety, low mood, fatigue, and difficulty concentrating. Observations include a flat affect and tearfulness during the session.
Area(s) of functional impairment:  
The client's symptoms are affecting her work performance, as she struggles to meet deadlines and maintain focus. She also reports withdrawing from social activities and experiencing strained relationships with family members.
History of mental health treatment/substance use treatment:  
The client has a history of attending therapy sessions for anxiety during her college years but has not engaged in any treatment since then. No substance use treatment history is reported.
Family history of mental health/substance use including treatment, if any:  
The client's mother has a history of depression and was treated with medication and therapy. No substance use issues are reported in the family.
Psychosocial:  
The client is currently employed as a marketing manager but is concerned about job security due to her declining performance. She has no legal issues but is experiencing financial stress due to student loans.
Interpersonal/family information:  
The client describes her relationship with her family as supportive but distant. She has a few close friends but has been avoiding social interactions. She is single and not currently in a romantic relationship.
Current living situation:  
The client lives alone in a rented apartment. She reports feeling isolated and occasionally worries about the risk of losing her housing due to financial instability.
Cultural considerations:  
The client identifies as Hispanic and mentions that cultural stigma around mental health has made it difficult for her to seek help. She feels pressure to appear strong and self-reliant.
Trauma and/or Abuse History:  
The client reports experiencing emotional abuse from a previous partner, which contributes to her current anxiety. No other trauma is noted.
Client Strengths:  
The client is articulate and demonstrates insight into her condition. She has a supportive network of friends and family and is motivated to improve her mental health.
Substance Use
Current Substance Use:  
N/A
Previous substance use:  
None
Health history and/or current medical conditions:  
No relevant past or present health concerns reported.
Current medications:  
Sertraline, 50mg, prescribed for depression and anxiety.
Primary Care Physician: Dr. Emily Carter, (555) 123-4567, last routine exam on 1 September 2024.
Psychiatrist/NP: None Reported
Risk Assessment
1. Columbia Suicide Severity Rating Scale (C-SSRS):  
N/A
2. Client denies any current or past suicidal ideation.
MSE (Mental Status Exam)
1. Mood: Depressed  
2. Appearance: Well-groomed  
3. Thought Process: Linear, goal-directed  
4. Rapport: Cooperative  
5. Thought Content/Perceptions: Normal  
6. Behavior: Normal  
7. Cognition: Normal, Fully Oriented  
8. Speech: Normal  
9. Insight: Good  
10. Affect: Constricted  
11. Judgment: Fair  
Clinical Summary  
The client presents with symptoms consistent with generalized anxiety disorder and major depressive disorder, impacting her occupational and social functioning. Treatment is needed to address these symptoms and improve her quality of life.
Diagnosis  
Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD)
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "History of Present Illness" clinical template is an essential tool for healthcare professionals seeking to conduct comprehensive patient assessments. This template is meticulously designed to capture critical information, including the patient's presenting problems, current symptoms, and areas of functional impairment. It also delves into the patient's history of mental health and substance use treatment, family history, and psychosocial factors, providing a holistic view of the patient's condition. Clinicians can document interpersonal relationships, current living situations, cultural considerations, and any history of trauma or abuse, ensuring a thorough understanding of the patient's background. The template also includes sections for assessing client strengths, current and previous substance use, health history, and current medications, along with details of primary care and psychiatric providers. A risk assessment component, featuring the Columbia Suicide Severity Rating Scale (C-SSRS), is included to evaluate suicidality. The Mental Status Exam (MSE) section allows for detailed observations of mood, appearance, thought processes, and more. Finally, the clinical summary and diagnosis sections guide clinicians in formulating an initial diagnosis and treatment plan. By adopting this template, healthcare providers can enhance their diagnostic accuracy and treatment efficacy, ultimately improving patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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BPS Assessment