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Biopsychosocial assessment template
Use this for initial evaluations that need the full picture—biological, psychological, and social domains—plus a formulation and treatment recommendations that drive the care plan.
Template content
Copy or download, then paste into Wavo under My Templates.
Biopsychosocial Assessment Identifying Information / Referral - Age, pronouns as documented, referral source, and reason for assessment. - Historians if other than the client. Chief Concern - Client’s stated problems and goals in their words when possible. Biological Domain - Medical conditions, medications, allergies, sleep, appetite, pain, substance use, and developmental/neurologic history as relevant. - Psychiatric medication history if discussed. Psychological Domain - Symptom history (onset, course, severity), prior diagnoses/treatment, trauma history as disclosed, cognitive/emotional functioning. - Mental status observations; screening scores if obtained (do not invent). - Coping style, personality strengths/traits as clinically relevant, and insight. Social Domain - Living situation, relationships, supports, occupational/school functioning, finances, legal issues, cultural/spiritual context, and social determinants. - Safety in relationships / IPV concerns if assessed. Risk Assessment - SI/HI/self-harm history and current status; risk level with rationale; protective factors. Strengths & Barriers - Client strengths, motivation, and barriers to engagement/change. Clinical Formulation - Integrative biopsychosocial formulation linking domains to presenting problems. - Diagnostic impressions / differential as appropriate to scope of practice. Recommendations / Plan - Level of care, modality recommendations, referrals (psychiatry, medical, social services), frequency, and initial goals. - Safety plan elements if indicated; consent/limits of confidentiality reviewed if done.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Forces balanced coverage across bio/psycho/social domains, not symptoms alone.
- Produces a formulation clinicians can reuse in treatment planning.
- Fits psychology intakes and therapy admissions that need more than a DAP stub.
- Keeps risk, strengths, and cultural/contextual factors visible.
- 1Psychology and therapy intakes
- 2Comprehensive outpatient behavioral-health assessments
- 3Treatment-plan foundation evaluations
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Chief Concern “Anxiety and burnout—I can’t turn my brain off after work.” Goals: sleep better and stop canceling plans. Biological Insomnia 4–5 hours; caffeine 3 coffees/day; no known medical dx; rare alcohol; denies illicit substances. Not on psychotropics. Psychological GAD symptoms ×2 years, worse 6 months. PHQ-9 = 10; GAD-7 = 15. Prior short counseling helpful. Denied trauma details today. MSE: anxious, linear, insight fair. Social Lives with partner; supportive. Software role with long hours. Limited friends locally; family out of state. No legal issues. Identifies as LGBTQ+; affirming supports present. Risk Passive SI last month without plan/intent; none currently. Protective: partner, dog, career goals. Risk low-moderate. Formulation Generalized anxiety amplified by sleep debt, high job demand, and reduced recovery activities; strengths include insight and partner support. Plan Weekly CBT for worry/sleep; sleep hygiene + caffeine taper psychoeducation; consider psychiatry referral if GAD-7 remains ≥15 at week 6. Safety resources provided. Next: treatment plan session.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
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