Comprehensive Psychiatric Evaluation Template

Chief Complaint

Comprehensive Psychiatric Evaluation Template

Most distressing Symptoms(s)

[Describe the patient's most distressing symptoms, including onset, duration, and impact on daily life.]

Current Medications

[List all current medications, including dosages and frequency.]

Past Medications

[List past medications, including reasons for discontinuation if known.]

Past Psychiatric Dx

[Provide a list of past psychiatric diagnoses.]

Past Psychiatric Hospitalizations

[Detail any past psychiatric hospitalizations, including dates and reasons.]

Past Substance Abuse Treatment

[Describe any history of substance abuse treatment, including types of treatment and outcomes.]

Sponsor

[Indicate if the patient has a sponsor and provide details if applicable.]

12 steps

[Note the patient's involvement in 12-step programs, if any.]

Violent behaviors

[Document any history of violent behaviors.]

Self-Harm

[Note any history of self-harm behaviors.]

Suicide attempts

[Detail any history of suicide attempts, including dates and circumstances.]

Medication trials

[Provide information on past medication trials, including effectiveness and side effects.]

Medical History

[Summarize the patient's medical history, including chronic conditions and surgeries.]

Allergies

[List any known allergies, including medication, food, and environmental allergens.]

Sleep quality

[Provide details on the patient's sleep quality and any related issues.]

Hallucination/Delusions

[Detail any history or current experiences of hallucinations or delusions.]

Trauma

[Describe any history of trauma, including type and impact.]

Born and Raised

[Provide details on the patient's place of birth and upbringing.]

Family

[Describe the patient's family structure and relationships.]

Family history of mental health/addiction

[Document any family history of mental health issues or addiction.]

Mother

[Provide details on the mother's mental health and addiction history.]

Father

[Provide details on the father's mental health and addiction history.]

Siblings

[Provide details on siblings' mental health and addiction history.]

Housing

[Describe the patient's current housing situation.]

Education

[Provide details on the patient's educational background.]

Financial

[Describe the patient's financial situation.]

Legal Problems

[Note any legal issues the patient has faced.]

Positive Supports

[Document the patient's positive support systems.]

Living arrangement

[Describe the patient's current living arrangement.]

Safety Concerns/feels safe

[Note any safety concerns or if the patient feels safe in their environment.]

Children/Active parent

[Provide details on the patient's children and parenting status.]

Outpatient treatment

[Detail any outpatient treatments the patient has undergone.]

Depression

[Describe the patient's history and current status regarding depression.]

Anxiety

[Describe the patient's history and current status regarding anxiety.]

OCD

[Note any history or symptoms of obsessive-compulsive disorder.]

Psychosis

[Document any history or symptoms of psychosis.]

PTSD

[Note any history or symptoms of post-traumatic stress disorder.]

Bipolar

[Document any history or symptoms of bipolar disorder.]

ADHD

[Note any history or symptoms of attention-deficit/hyperactivity disorder.]