Healthcare BH EQI Tool

HEALTHCARE BH EQI TOOL

Purpose: This Behavioral Health Equity and Quality Improvement (BH EQI) Tool collects clinical, demographic, social-determinant, and equity-related information to support individualized treatment planning and program-level quality improvement. Information documented on this form will be used for clinical care, case management, and de-identified quality improvement analyses. Participation is voluntary; refusal will not affect access to care. By signing below, the patient authorizes the use of clinical data as described in the Authorization for Use of Data section.

Patient Information

Patient Name:

Insurance Information

Medical & Behavioral Health History

Presenting Behavioral Health Concerns

Check current symptoms (select all that apply):

Depressed mood
Anxiety / Panic
Trauma symptoms / PTSD
Psychotic symptoms
Substance use concerns
Sleep disturbance

Immediate Safety Flags:
Suicidal ideation / intent
Homicidal ideation / intent
Recent attempt / self-harm
Acute substance withdrawal risk
Safety plan in place:

Screening Instruments / Scores

Social Determinants & Access

Housing status: Stable Unstable / Homeless

Employment / Income insecurity: Yes

Equity & Cultural Considerations

Interpreter services needed: Yes

Race / Ethnicity:    Sexual orientation:

Health literacy concerns (difficulty understanding health information): Yes

Clinical Assessment & Care Plan

Equity & Quality Improvement Authorization

Authorization: I authorize the use of my behavioral health information documented on this BH EQI Tool for the purposes of clinical care, internal quality improvement, equity analysis, and program evaluation. Information used for quality improvement will be de-identified or limited to the minimum necessary when aggregated for reporting. I understand that this authorization does not permit disclosure of psychotherapy notes separate from the clinical record unless I specifically authorize such release in writing.

I consent to the authorized use of my de-identified clinical information as described above.

Revocation: I understand I may revoke this authorization at any time by submitting a written revocation to my treating provider. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of revocation.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or provided a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights related to that information.

I acknowledge receipt or offer of the Notice of Privacy Practices.

Clinician / Administrative Use

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