Psychiatric intake template

Psychiatric Intake Note

Chief Complaint
- Document the patient's stated reason for presentation in their words when possible.

History of Present Illness
- Onset, course, precipitants, and current symptoms (mood, anxiety, psychosis, trauma, sleep, appetite, energy, concentration, interest).
- Functional impact at work, school, relationships, and self-care.
- Include relevant screening scores discussed (e.g., PHQ-9, GAD-7) with date/context.

Psychiatric History
- Prior diagnoses, hospitalizations, outpatient treatment, and response to therapy or medications.
- Past suicide attempts, self-harm, or violence history if discussed.

Medication History
- Current psychotropic medications with dose, adherence, response, and adverse effects.
- Prior medication trials and reasons for discontinuation.

Medical / Substance / Family / Social History
- Relevant medical conditions, substances (including caffeine/nicotine), family psychiatric history, and social supports/stressors.

Mental Status Examination
- Appearance, behavior, speech, mood, affect, thought process/content, perception, cognition, insight, and judgment.

Safety / Risk Assessment
- Suicidal ideation, plan, intent, means; homicidal ideation; protective factors; level of risk and rationale.

Assessment
- Diagnostic formulation and differential using clinically appropriate terminology.
- Clinical complexity and contributing psychosocial factors.

Plan
- Medications, therapy referrals, labs/monitoring if indicated, safety plan, follow-up interval, and patient education.