Psychiatric Initial Evaluation

Patient Information

Patient Name: Date of Birth: Phone Number: Address:

History of Present Illness (HPI)

Duration of Symptoms Onset of Symptoms Severity of Symptoms Triggers or Aggravating Factors Coping Mechanisms Past Treatments or Interventions Current Medications or Therapy Patient Narrative Summary

Past Psychiatric History

Previous Diagnoses Past Treatment Settings

Inpatient Outpatient Emergency Care

Previous Hospitalizations Previous Medications Suicide Attempts or Self-harm Homicidal Ideation Substance Use History

Family History

Family History of Mental Illness Family History of Substance Abuse

Medical History

Current Medical Conditions Past Surgeries or Hospitalizations Medication Allergies Non-Psychiatric Medications Medication Compliance

Social History

Living Situation Occupation or School Status Marital Status Support System Substance Use (Current)

Alcohol Tobacco Drugs

Legal History Recent Stressors

Detailed Mental Status Examination (MSE)

Appearance Behavior Speech Mood Affect Thought Process Thought Content Cognition Insight Judgment Additional Narrative (Optional)

Assessment

Diagnosis (Select or type to add more)

Treatment Plan

Therapeutic Interventions Medications Initiated or Adjusted Medication Details (Name, Dose, Frequency) Psychiatric Follow-up Therapy Follow-up Referrals Made

Primary Care Physician (PCP) Therapist/Counselor Substance Use Treatment Social Work / Case Management

Plan

Continue psychiatric monitoring Review medication adherence & side effects Schedule follow-up appointments Provide patient education on diagnosis/treatment Safety planning / Crisis intervention

Plan Notes (Narrative)