Biopsychosocial assessment: the domains, a template and a substance use example

What a biopsychosocial assessment is, and what it isn't

The word comes from the biopsychosocial model George Engel proposed in 1977, which argued that illness can't be understood from biology alone and that psychological and social factors belong in the picture (Engel, Science, 1977). In behavioral health, the BPS is where that idea becomes paperwork: one interview, written up in a fixed order, that every later document points back to. It sits between a short screening and the treatment plan, and it's easy to confuse with the documents around it:

Document	What it does	When
Screening	Decides whether the person fits the program and whether anything is urgent (withdrawal, suicide risk, medical danger)	First call or first visit, before admission
Biopsychosocial assessment	The full history and current picture, a diagnostic impression, and the problems, needs and strengths list	At admission; in a Texas SUD program, signed within 3 individual service days
ASAM level-of-care assessment	Rates risk in each ASAM dimension and recommends a level of care, for substance use	At admission, then at each review
Psychiatric diagnostic evaluation	The billing name for an intake evaluation by a licensed clinician (CPT 90791, or 90792 with medical services)	Usually the same visit as the BPS
Treatment plan	Turns the problems list into goals, measurable objectives and services	After the assessment; in Texas within 5 individual service days

ASAM draws the same line in the 4th edition of its Criteria: its level of care assessment is the shorter interview used to recommend a level, and a full biopsychosocial assessment isn't needed for that recommendation, but it is the foundation of a comprehensive treatment plan (ASAM level of care assessment guide). In many outpatient programs, ours included, the two are done in one sitting and written as one document, organized so the ASAM ratings can be read straight out of it.

The domains, one by one

Forms differ in order and labels, but a complete BPS covers these domains. The third column marks the 11 areas the Texas rule for chemical dependency treatment facilities requires (26 TAC §564.803(a)); the rest are what payers' reviewers and Medicare contractors look for in an intake evaluation.

Domain	What to record	Texas area?
Presenting problem	Why now, in the client's own words; who referred them; what happened that brought them in this week, not this year	Yes
Alcohol and drug use	Each substance: age of first use, pattern in the last 30 days, amount, route, last use (date and time); withdrawal and overdose history; tobacco and nicotine	Yes
Treatment history	Past treatment by level and date, how each ended, medications for opioid or alcohol use disorder, mutual-help groups, longest time without use	Yes
Medical history	Conditions, current medications and allergies, pregnancy, pain, the primary care contact, and risk behaviors for tuberculosis, HIV and sexually transmitted infections	Yes (TB, HIV and STD risk named in the rule)
Mental and emotional functioning	Past diagnoses, hospitalizations and psychiatric medications, trauma, current symptoms, and standardized scores (PHQ-9, GAD-7) with the date	Yes
Risk	Suicide and self-harm (a structured screen such as the Columbia), violence, overdose risk, and what you did about each answer that wasn't "no"	Part of mental and emotional functioning
Mental status	Appearance, behavior, speech, mood and affect, thought process and content, perception, orientation and memory, insight and judgment	No; expected in an intake evaluation billed to Medicare
Family relationships	Household, family of origin, family substance use and mental health, children and custody, partner, violence at home	Yes
Social and leisure	Friends who use and friends who don't, how free time is spent, faith or spirituality if the client names it, recovery supports	Yes
Education	Highest level, reading level if it affects treatment, learning needs	Yes
Employment	Job, schedule, whether use has affected work, income, military service	Yes
Legal problems	Open charges, probation or parole and the officer's name, court orders, CPS involvement, driving status	Yes
Housing and basic needs	Where they sleep, whether anyone there uses, safety, transportation, food, phone, insurance	No, but it is ASAM dimension 5
Strengths and weaknesses	What has worked before, skills, people, motivation; what gets in the way. The client's goals in their words	Yes
Diagnostic impression	Each diagnosis by current DSM criteria with its ICD-10-CM code, within the assessor's scope of practice	Required output (§564.803(d))
Summary and recommendations	The problems, needs and strengths list, the level of care, referrals, and what happens next	Required output (§564.803(c))

Write facts, not adjectives. "Drinks heavily" is an opinion; "8 to 10 beers a night, 6 nights a week, last drink 10/26 at 11 p.m." is something the next clinician, the reviewer and the client can all check.

Texas: what 26 TAC 564 requires, and when

For a licensed chemical dependency treatment facility, chapter 564 of the Texas Administrative Code sets who does the assessment, what it covers and the deadline. Our sister site summarizes the whole chapter in its 26 TAC 564 guide; these are the assessment rules, from §564.803 unless noted:

Rule	What it says
Who does it	A counselor or counselor intern completes the comprehensive psychosocial assessment at admission, covering the 11 areas above
By video	Allowed by electronic means with synchronous audio and video. Audio-only only during a declared state of disaster, under the rule's conditions. In person if the client asks, or doesn't give verbal consent to an electronic assessment
What it produces	A comprehensive list of the client's problems, needs and strengths, and a diagnostic impression under current DSM standards
Mental health	If the assessment finds a possible mental health problem, the program gets a mental health assessment and services, in-house or by referral (§564.803(e))
Deadline and signature	A qualified credentialed counselor (QCC) signs it and files it in the record within 3 individual service days of admission (§564.803(f))
Outside assessments	An evaluation done in the 30 days before admission, or sent by a transferring facility, can be used if a counselor reviews it with the client and documents an update (§564.803(g))
Residential only	A licensed health professional completes a physical health assessment within 96 hours of admission (§564.803(h))
The plan after it	Treatment plan within 5 individual service days, built from the assessment (§564.804)

"Individual service day" means a day the client actually receives services, not a calendar day (§564.1). An IOP client who comes Monday, Wednesday and Friday and starts on a Monday reaches service day 3 that Friday. Counting calendar days instead is never late. These rules bind licensed facilities; a counselor in private practice follows their own license board's rules and each payer's manual instead. The admission path around the assessment, from first call to first group, is in Cima Consulting's IOP admissions process.

Medicare and Medicaid documentation

A payer doesn't pay for "a BPS." It pays for an intake evaluation code, and the BPS is the documentation behind it.

• Commercial plans and Medicare pay the intake as the psychiatric diagnostic evaluation: 90791, or 90792 when a physician or nurse practitioner adds medical services. One Medicare contractor's coverage policy lists what the evaluation should hold: the reason for the visit and the referral source, the history of the present illness, psychiatric, medical, social and family history, a mental status exam, strengths and liabilities, a diagnosis or problem list, and treatment recommendations. If family is interviewed instead of the patient, the note says why (LCD L33252). A legible signature and a diagnosis the documentation supports are required (billing article A57520).
• Not with therapy the same day. Medicare's correct coding policy says 90791 and 90792 aren't separately reportable with individual, group, family or crisis psychotherapy on the same date (NCCI Policy Manual, chapter XI, 2026). Plan the assessment as its own visit.
• Texas Medicaid pays a substance use assessment as H0001: a multi-dimensional assessment on admission, done by a QCC or a counselor intern and signed off by a QCC, limited to once a day for any provider and once per episode of care (TMPPM Behavioral Health handbook, October 2026). Plan for one H0001 per episode; an update later in the same episode isn't a second H0001.
• Program days (IOP and PHP per diems) often include the assessment in the day's rate; check your contract before billing it on top. IOP and PHP billing codes covers what a per diem includes.

The time rules, add-ons and same-day limits for the evaluation and therapy codes are in behavioral health billing guidelines.

A made-up example: substance use, written up

Client L., 29, admitted to an outpatient program. Every detail is invented; the point is the shape and the level of specificity.

Notice what makes it useful: dates and amounts, her words in two places, a risk answer followed by what was done, and a problems list that the plan can copy line by line. The six ASAM ratings that justify Level 2.1 would sit right after it; the ASAM Criteria cheat sheet has a worked placement of that part.

A biopsychosocial assessment template (free to copy)

Copy this table into your EHR's template or a document. Each row is a section heading; the middle column is what to answer. Add your own state's required wording where its rules give one.

Section	Answer these	Notes for the writer
1. Identifying information	Name, date of birth, a second identifier, date and start and stop time of the interview, in person or video, who else was present, interpreter used	Video: record the client's location and consent for this session
2. Presenting problem	Why now? Referral source? What does the client want to change, in their words?	Quote at least one sentence
3. Substance use	For each substance: first use, last-30-day pattern, amount, route, last use; withdrawal history; overdose history; tobacco	A grid works best, one row per substance
4. Treatment history	Each past episode: level, dates, how it ended; medications for addiction; mutual-help; longest time without use	Ask for releases to get the records
5. Medical	Conditions, medications, allergies, pregnancy, pain, primary care; TB, HIV, STD and hepatitis risk behaviors	Texas programs: the TB, HIV and STD line can't be blank
6. Mental health	Past diagnoses, hospitalizations, psychiatric medications, trauma; current symptoms; PHQ-9 and GAD-7 scores with dates	A possible mental health problem needs an assessment or referral
7. Risk	Suicide and self-harm screen result; violence; overdose risk; safety plan and actions taken	Never leave a positive answer without a response
8. Mental status	Appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight, judgment	Observed, not reported
9. Family	Household; family of origin; family use and mental health; children and custody; partner; safety at home	Who could join family sessions?
10. Social, leisure and spirituality	Supports who don't use; free time; faith if important to the client; recovery community	Name people, not "has supports"
11. Education	Highest level; learning or reading needs	Affects handouts and homework
12. Employment and income	Work, schedule, income, effect of use on work, military service	The schedule shapes the track you offer
13. Legal	Charges, probation or parole, court orders, CPS, driving status	Releases for any legal contact, limited to what's needed
14. Housing and basic needs	Where they live, who uses there, safety, transportation, food, phone, insurance	Feeds ASAM dimension 5
15. Strengths, weaknesses and preferences	What has worked; skills and people; barriers; what the client wants from treatment	Feeds ASAM dimension 6
16. Diagnostic impression	Each diagnosis (current DSM) with ICD-10-CM code; rule-outs	Within your scope of practice
17. Problems, needs and strengths list	Numbered list, one line each	Each item goes on the plan, is referred out, or is deferred with a reason
18. Recommendations	Level of care, services, referrals, next appointment, plan due date	For SUD, the ASAM ratings and the level go here or right after
19. Signatures	Assessor's name, credentials, date and time signed; supervising or QCC signature and date	Texas SUD programs: QCC within 3 individual service days

The questionnaire a client fills in before the interview is in our counseling intake form template. Running a licensed program? The packet of forms around the assessment (consent, privacy notice, Part 2 consent, rights) is on Cima Consulting's intake packet checklist.

How the BPS feeds the ASAM assessment

For substance use, a well-ordered BPS already holds nearly every fact the ASAM ratings need. This is where each one comes from, using the 4th edition dimension names:

ASAM dimension (4th edition)	BPS sections it draws on
1. Intoxication, Withdrawal, and Addiction Medications	Substance use (last use, withdrawal and overdose history), treatment history (medications), medical (current prescriptions)
2. Biomedical Conditions	Medical history, pregnancy, pain, primary care
3. Psychiatric and Cognitive Conditions	Mental health, risk, mental status, education (cognitive or learning needs)
4. Substance Use-Related Risks	Substance use pattern, cravings, treatment history (how past attempts ended)
5. Recovery Environment Interactions	Family, social, housing, employment, legal
6. Person-Centered Considerations	Strengths and preferences, practical barriers (transport, childcare, schedule), the client's goals

The dimension names are ASAM's; the mapping is ours. What the ratings mean and how the levels compare is in the ASAM Criteria cheat sheet, and how to run the interview and set the level is in how to complete an ASAM assessment. Mental-health-only clients don't get ASAM ratings; the BPS's recommendations section carries the level-of-care reasoning instead.

How it feeds the treatment plan

The Texas rule is the simplest test: every problem and need found in the assessment ends up on the plan, referred to someone else, or deferred with a written reason (§564.804(a)). Surveyors read the assessment's list next to the plan and look for anything that disappeared. From Client L.'s list:

Problem from the BPS	Where it went
1. Opioid use, recent overdose	Plan problem 1: goal "stay alive and stop using opioids"; objective "take buprenorphine daily and report doses at each session through 12/15; name 3 triggers and a plan for each by 11/14"
2. Depression, passive suicidal thoughts	Plan problem 2, plus a psychiatric evaluation referral; objective "PHQ-9 below 10 by 12/15, measured every 2 weeks; review the safety plan weekly"
3. Hepatitis C, no primary care	Referred: primary care and hepatitis C appointments by 11/30, tracked in notes
4. Friends who use	Plan problem 3: two meetings a week and one sober contact named by 11/21
5. Unemployment	Deferred until after the first plan review: "client chose to focus on early recovery first"
6. Probation	Plan intervention: monthly attendance letter under the signed release

How to write the goals and measurable objectives themselves, with a full sample plan and a blank template, is in the SUD treatment plan guide. After that, each progress note names the goal it worked on, so the line from the assessment to the bill stays unbroken.

What reviewers flag in assessments

• Copied forward from a past episode, or from another client, with old dates and old use.
• No client voice: the presenting problem written entirely in clinical language.
• A risk answer with no response: a positive suicide item and no safety plan or action that day.
• Diagnosis without support: "opioid use disorder, severe" with nothing in the history that shows the criteria.
• Blank required areas, most often the TB, HIV and STD risk line, legal history or strengths.
• Late or unsigned: in a Texas SUD program, no QCC signature by service day 3.
• Problems that vanish: on the assessment's list but not on the plan, referred or deferred.

Comply's chart audit checklist checks these chart by chart.

Biopsychosocial assessments in Cima

Cima EHR includes an intake assessment template that asks for the presenting problem in the client's words, the substance use and psychiatric history, and your diagnostic impression, and bills as 90791 or H0001 (see Cima for addiction counselors). On the Program plan for IOP and PHP, the biopsychosocial assessment covers each substance, withdrawal and overdose history, past treatment and recovery, and ASAM dimensions 1 to 6 with a risk rating for each, and due dates for the assessment, the treatment plan and plan reviews run in calendar days you set (the defaults are 3, 5 and every 30). Clients fill in the PHQ-9 and GAD-7 on their phone before they arrive, and a self-harm answer alerts you right away. Type or dictate a few lines and, if the practice owner has turned it on, AI drafts the sections from only what you wrote, for you to edit and sign. See Cima for IOP and PHP programs and notes in the feature list.

Questions

What is a biopsychosocial assessment?

A structured intake interview that covers a person's biological, psychological and social situation (physical health and substance use; mental health and safety; family, housing, work, school, legal and supports) and ends in a diagnostic impression, a list of problems, needs and strengths, and recommendations for care.

What are the components of a biopsychosocial assessment?

The presenting problem, substance use, treatment history, medical history, mental health and risk, a mental status exam, family, social and leisure, education, employment, legal, housing and basic needs, strengths and preferences, the diagnostic impression, and a summary with recommendations. Texas SUD programs must cover 11 named areas.

Is a psychosocial assessment the same as a biopsychosocial assessment?

In practice, yes: most forms use the names for the same comprehensive intake. The Texas rule for chemical dependency facilities calls it a comprehensive psychosocial assessment, and it still requires medical history, so the biological part is there either way.

Who can complete a biopsychosocial assessment?

A licensed clinician working within their scope, in most settings. In a licensed Texas chemical dependency treatment facility, a counselor or counselor intern completes it and a qualified credentialed counselor signs it within 3 individual service days of admission.

How long does a biopsychosocial assessment take?

No rule sets a length. It takes as long as covering every domain takes, and it can span more than one session as long as it's finished and signed by the deadline. In a Texas SUD program, that's 3 individual service days.

Is there a CPT code for a biopsychosocial assessment?

It's billed as the psychiatric diagnostic evaluation: 90791, or 90792 when a physician or nurse practitioner adds medical services. Texas Medicaid pays a substance use assessment as H0001, once per episode of care. Medicare's coding policy doesn't allow 90791 or 90792 with psychotherapy on the same date.

Is there a free biopsychosocial assessment template?

Yes: the template table on this page is free to copy into your EHR or a document. Add your state's required wording, and for substance use, add the ASAM dimension ratings after the recommendations.

How does a biopsychosocial assessment differ from an ASAM assessment?

The BPS is the full history and current picture, the base of the treatment plan. The ASAM level of care assessment rates risk in six dimensions to recommend a level of care. ASAM's 4th edition says the full BPS isn't needed for the level recommendation but is the foundation of the treatment plan. Many programs do both in one interview.

Can a biopsychosocial assessment be done by telehealth?

Generally yes, if the payer allows it. Texas SUD facilities may assess by synchronous audio and video; audio-only is allowed only during a declared state of disaster under the rule's conditions, and the assessment is in person if the client asks.

How often should the assessment be updated?

At each new episode of care, and when something major changes (a new diagnosis, a relapse that changes the level of care, a move or a legal change). Texas programs can use an outside assessment from the 30 days before admission only after reviewing it with the client and documenting an update.

What is the biopsychosocial model?

An approach to illness proposed by psychiatrist George Engel in 1977 in Science: that biological, psychological and social factors all have to be considered to understand and treat a person, not biology alone. The assessment takes its name from it.

Sources

1. George L. Engel, "The Need for a New Medical Model: A Challenge for Biomedicine," Science 196 (4286): 129–136, April 8, 1977. science.org
2. 26 Texas Administrative Code §564.803, assessment (as of October 2026). Cornell LII
3. 26 Texas Administrative Code §564.804, treatment planning, and §564.1, definitions ("individual service day"). §564.804 · §564.1
4. American Society of Addiction Medicine, The ASAM Criteria, Fourth Edition, level of care assessment guide; The ASAM Criteria, 4th edition.
5. CMS, Local Coverage Determination L33252, psychiatric diagnostic evaluation and psychotherapy services (elements of the diagnostic evaluation). Medicare Coverage Database
6. CMS, Billing and Coding article A57520 (signatures, documentation). Medicare Coverage Database
7. CMS, Medicare NCCI Policy Manual, chapter XI, revised January 1, 2026 (90791 and 90792 with psychotherapy).
8. TMHP, Texas Medicaid Provider Procedures Manual, Behavioral Health handbook, October 2026 (H0001).

CPT is a registered trademark of the American Medical Association. "The ASAM Criteria" is ASAM's registered trademark; dimension names are used for reference and this page isn't affiliated with ASAM. General information, not clinical, legal or billing advice.