1. Add the template
Paste this content into My Templates, or start from a specialty-generated template and edit the sections.
Psychiatric intake template
Use this psychiatric intake template as a starting point in Wavo. Paste it into a custom template, set it as default for new evaluations, and let ambient or dictation capture fill the sections from the visit.
Template content
Copy or download, then paste into Wavo under My Templates.
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.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Covers the full first-visit story without forcing a primary-care SOAP shape.
- Keeps risk, MSE, and medication history as first-class sections.
- Leaves room for screening scores (PHQ-9, GAD-7) when discussed.
- Easy to customize—add or remove sections to match your clinic’s intake packet.
- 1New outpatient psychiatric evaluations
- 2PMHNP and psychiatrist intakes
- 3Telepsychiatry first visits
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Interval History Patient presents for initial psychiatric evaluation of worsening anxiety and low mood over 8 weeks. PHQ-9 today 16; GAD-7 14. Sleep reduced to 4–5 hours with early awakening. Denies manic symptoms. Reports passive suicidal ideation without plan or intent. Mental Status Alert, casually dressed, cooperative. Mood “anxious and down,” affect congruent and restricted. Thought process linear. No hallucinations. Insight fair; judgment intact for safety decisions. Safety / Risk Passive SI without plan/intent/means. Protective factors include children and ongoing therapy. Risk assessed as low-moderate; safety plan reviewed. Assessment Major depressive disorder, recurrent, moderate, with anxious distress. Rule out GAD as comorbid. Medication Response No current antidepressant. Prior sertraline trial stopped for GI side effects. Plan Start escitalopram 5 mg daily with education on onset and side effects. Continue weekly therapy. Follow up in 2 weeks. Crisis resources provided.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.