Counselors, therapists, and other behavioral health professionals should use a biopsychosocial evaluation framework to learn about their clients on multiple levels and get a deeper understanding of their subjective perspective and viewpoint. Psychological, biological, and sociocultural factors which may be contributing to a client's issues, concerns, and difficulties are identified through an examination and holistic assessment of the individual.

In this webinar, we will review the history of present illness, past psychiatric history, medical history, social history, and family history. We will review how to properly document level of care justification for payor sources. Finally, we will cover how using an electronic medical record system to document mental health treatment can improve efficiency, allowing practitioners to devote their time and attention to individuals who need their assistance.