Psychiatric Consultation Template - 11/26/2025

OVERALL_INSTRUCTIONS

Highly Detail, make sure all relevant information mentioned is capture and included.

Template

Name of Patient: [Patient Name] Date of Birth: [Patient DOB] Family/Referring Doctor: Dr. [Referring Doctor Name] Other Health Care Professionals: [List of Other Professionals mentioned, including housing worker, primary worker, previous psychiatrist, addiction medicine, and morealong with their title/role] Date of Assessment: [Date of Assessment] Attendees and Confidentiality: I reviewed doctor-patient confidentiality and its limitations, including situations in which there may be imminent risk to self or others, inability to care for self, child safety, driving safety, and legally mandated disclosure. [Ms. or Ms..] [Case worker's or Primary worker s name] was present for the assessment. Patient has granted permission to use Empathia AI for assistance with report generation. Reason for Referral: [Provide a brief summary of the reason for referral, including the patient's primary concerns, symptoms, and any associated factors. For example: 'The patient reports [symptoms] related to [issues], with associated [additional symptoms or factors].'] Chief Complaint: [Chief Complaint] History of Present Illness: [[Provide a extremely detailed narrative of the patient's current health issues, including the following elements: Description of mood and emotional state, including any fluctuations and contributing factors such as social isolation or lack of relationships. Specific symptoms experienced on both good and bad days, with mood ratings on a scale of 1 to 10. Impact of lifestyle factors such as smoking on mood and physical symptoms, including appetite and sleep. Behavioral symptoms such as restlessness or pacing, with any relevant historical context. Any perceptual disturbances, including auditory hallucinations, with details on their nature, frequency, and impact on the patient. Current and past psychiatric treatments, including medications prescribed and their effects on symptoms. Functional impairments in daily living activities and the level of support required from family or others. Patient's employment status and sources of financial support. Participation in therapeutic activities and their perceived benefits. Patient's expressed desires for independence and social connection, along with perceived limitations due to symptoms and circumstances.] For example: He describes a longstanding history of depressed mood, which he attributes primarily to social isolation and the absence of a romantic relationship. He reports that his mood fluctuates, with some days being significantly worse than others. On days when he feels depressed, he rates his mood as 4 or 5 out of 10, whereas on better days, he rates it as 10 out of 10. He identifies loneliness and the desire for a romantic relationship as major contributors to his depressive symptoms. He has never been in a significant romantic relationship, which he perceives as a source of distress. He also reports that not having cigarettes exacerbates his mood symptoms, leading to increased sluggishness, overeating, and difficulty sleeping. He smokes approximately half a pack of cigarettes per day and notes that smoking helps suppress his appetite and sometimes aids sleep. He experiences restlessness and difficulty sitting still, often pacing around his small apartment, a symptom he has noticed since moving to Welland in 2021. He has also reported vague auditory perceptual disturbances, particularly when consuming media, but these are not persistent or commanding in nature. He has a history of hearing voices, which led to a recent psychiatric hospitalization when the perceptual disturbances became distressing. He does not recall the specific content of the voices but notes that they were not loud or clear. He denies current auditory hallucinations during the interview. He has been prescribed fluoxetine, initially for anxiety, and Invega (paliperidone) for auditory perceptual disturbances. He reports that fluoxetine has been helpful for anxiety and that Invega has reduced the frequency and intensity of auditory disturbances. He has experienced functional impairment in the form of difficulty maintaining daily living activities, such as washing dishes and managing household chores, often requiring assistance from his parents. He expresses frustration and feelings of incompetence related to his dependence on parental support. He is currently unemployed and receives financial support through ODSP. He has participated in group therapy, which he found helpful for reflecting on his thoughts and feelings. He expresses a desire for increased independence and social connection but feels limited by his symptoms and circumstances.] Rating Scales and Investigations: [Document any rating scales or questionnaires completed by the patient, including results and interpretations. Include any laboratory or imaging investigations conducted and their findings.] -GAD-7: [If mentioned, include details on Global Assessment of Functioning Score] - PHQ-9: [If mentioned, include details on Patient Health Questionnaire Score] - PRS: [If mentioned, include details on Psychiatric Rating Scale Score] - Other: [Other relevant scales or investigations if applicable] Allergies: [Document any known allergies, including medication, food, or environmental allergens. If no allergies are reported, state 'No known allergies.'] Medications: [[List all current medications, including dosages, frequency, and route of administration. Note any recent changes to medications, reasons for changes, and the patient's adherence to the prescribed regimen. Include any reported side effects or concerns related to medications.] For Example: She is currently prescribed multiple medications, including aspirin 81 mg, metformin, Ritalin, olanzapine 2.5 mg, Lupin Estradiol, medroxyprogesterone, Jardiance, lamotrigine, clonazepam, rosuvastatin, and amitriptyline 50 mg. She receives her medications in daily blister packs from Queen's Pharmacy and demonstrates adherence by picking up her medications daily. She reports that the antipsychotic and sedating medications, such as olanzapine and amitriptyline, cause residual sedation and cognitive dulling, which she finds distressing. She expresses concern that her current medications are not effective for her depressive and anxious symptoms. There is no history of recent medication changes.] Substance Use History: [[Document the patient's history of substance use, including type, frequency, and duration of use. Include any current substance use and its impact on the patient's health or symptoms. Note any history of substance use treatment or cessation efforts.] For example: She has a history of substance use, including past dependence on crack cocaine, which she discontinued approximately 17 years ago following an ultimatum from her daughter. She currently uses crystal methamphetamine daily, primarily by smoking, to manage anxiety and intrusive thoughts. She denies current use of alcohol and has not consumed alcohol since before her first pregnancy. She reports no history of recent alcohol use, no history of cannabis use since her teenage years, and no history of injecting drugs. She is enrolled in a Safer Supply Program for opioid use and receives daily observed dosing. She has participated in addiction treatment programs, including group therapy through Kaeson and individual support from Megan Cook. She denies recent hospitalizations for substance use. ] Medical History: [[Provide a detailed summary of the patient's medical history, including any chronic conditions, past surgeries, or significant medical events.] For example: She has a history of type 2 diabetes mellitus, complicated by lower limb amputation in September 2022 due to non-healing ulcers and perioperative complications. She reports a history of ischemic heart disease, with one and a half myocardial infarctions, and uses nitroglycerin spray as needed for stress-induced chest pain. She has a history of hepatitis B, which is not currently active. She underwent a hysterectomy following obstetric complications. She reports no current sexually transmitted infections, no history of thyroid issues, no history of recent trauma or injury, no history of recent seizures or neurological symptoms, and no history of recent infections or fever.] Psychiatric History: [[Summarize the patient's psychiatric history, including previous diagnoses, treatments, hospitalizations, and response to therapies. Include details about medications prescribed, their effectiveness, and any side effects experienced. Note any history of therapy or counseling and the patient's engagement with mental health services.] For example: She reports a complex psychiatric history, including previous diagnoses of bipolar disorder, personality disorder, and attention-deficit/hyperactivity disorder. She questions the accuracy of these diagnoses and seeks reassessment. She has a history of chronic depression and anxiety dating back to early childhood, with persistent symptoms and functional impairment. She reports a history of auditory hallucinations, which she attributes to trauma, but denies current psychosis. She has experienced multiple suicide attempts in the past. She has been prescribed various psychotropic medications, including antipsychotics (olanzapine, Seroquel), mood stabilizers (lamotrigine, lithium), stimulants (Ritalin), and sedating agents (amitriptyline, clonazepam), with limited efficacy and significant side effects. She has not been consistently prescribed antidepressant therapy. She has engaged with multiple mental health providers, including Dr. Nackney, Dr. Fulham, and Dr. Davidson, but has experienced discontinuity of care due to provider turnover and substance use history. She has participated in group and individual therapy intermittently. There is no history of mania or high mood episodes, no history of spending unnecessary amounts of money or gambling, no history of believing she had special powers or delusions of grandeur, and no history of recent gambling or risky financial behavior.] Family History: [[Summarize the patient's family history, including any psychiatric or medical conditions in immediate family members. Include details about family dynamics and support systems if relevant.] For example: Catharine's family history is notable for psychiatric and substance use disorders. Her mother, Linda, is of Ojibwe descent and has a history of depression treated with fluoxetine, as well as a history of alcohol use disorder, now in remission. Her father, of Welsh descent, died of dementia at age 60. Her daughters, Amanda and Carissa, have histories of substance use, including alcohol and opioid use disorders. Amanda also has thyroid problems and a history of depression. Her son, Joshua, is mentioned but no psychiatric or medical history is provided. There is a history of significant family discord, trauma, and loss of custody of her daughter Carissa. Her brother, Kevin, is a half-brother from her mother's side and is described as having problematic behavior but no specific psychiatric diagnosis.] Personal History: [[Provide a narrative of the patient's personal history, including details about their early development history. Include any significant life events or stressors that may impact their mental health. Note the patient's current living situation and level of independence.] For example: Catharine was raised in a context of significant family discord, with parental divorce at age five and subsequent instability in caregiving arrangements. She has experienced chronic housing instability and is currently homeless, residing in a tent near Gale Crescent. She receives financial support through Ontario Disability Support Program and is awaiting Disability Tax Credit approval. She has limited engagement with her Indigenous community but has accessed traditional medicine for nerve pain.] Relationship and Sexual History: [[Provide a detail summary of the patient's relationship and sexual history, if relevant to the assessment.] For Example: Marie is in a common-law relationship with Phil Brown, with whom she has lived for the past three years. She reports a supportive relationship and identifies him as a key support person. She has a history of inappropriate sexual behavior exposure in her childhood home and was sexually abused by a cousin at age five.] Abuse and Trauma History: [[Provide a detail narrative summary of the patient's abuse and trauma history. For any history of abuse or trauma, including dates and outcomes.] For Example: Marie reports a history of childhood emotional neglect, exposure to parental substance use, domestic violence, and inappropriate sexual behavior in the home. She was sexually abused by a cousin at age five. Her father was physically and sexually inappropriate while intoxicated.] Education & Employment History: [[Summarize the patient's educational background and employment history, including any relevant issues.] For Example: Marie previously worked at Gilmore Lodge but lost her job due to delays in medical paperwork during a period of medical testing and anxiety. She was previously on ODSP but is now financially supported by her partner. She denies currently working outside the home.] Legal History: [Document any legal issues or history of involvement with the legal system.] Mental Status Examination: - Appearance: The patient wore casual clothing, i.e., [description]. The patient had [hair_description] hair, wore glasses, and carried a [item]. - Orientation: [pronoun] was oriented to three spheres - person, place and date. - Behaviour: The patient’s behaviour was [description] for the setting. Patient was calm and cooperative, and developed good rapport with the interviewer. The patient had [eye_contact] eye contact. There was no psychomotor retardation or agitation. - Speech: The patient’s speech was of normal rate, rhythm, and volume. There was no pressure of speech. - Mood: The patient described [pronoun] mood as “[mood_description]”. On a zero to ten scale with 0 being suicidal and 10 being happy, the patient rated [pronoun] mood as “[number]” on most days, and “[number]” today. - Affect: The patient’s affect was neutral, except when [pronoun] described [pronoun] problems related to [issue]. [pronoun] affect was appropriate to [pronoun] thought content, was of normal range, and there was no lability. - Thought form: The patient’s thought form was [description]. There was no over-inclusiveness, tangentiality, or flight of ideas. - Thought content: The patient’s thought content consisted of responses to the interviewer’s questions, and focussed primarily on the patient’s concerns about [issue]. Patient had no suicidal or homicidal thoughts, intent or plan. There were no psychotic symptoms. - Perception: There were no hallucinations. - Cognition (Orientation, Memory and Attention): The patient had difficulty performing serial 7’s, and gave the following responses: [responses]. [pronoun] was able to recall three words immediately but only [number] on short term testing. With prompting, [pronoun] gave the responses “[response]” and “[response]”. - Insight: The patient had insight into the fact that [issue] has caused and is continuing to cause problems in [pronoun] interpersonal functioning, both with [pronoun] family and [pronoun] spouse. However, at times, [pronoun] still denies the impact of [issue] on [pronoun] life. Judgment: The patient appeared to have satisfactory judgment, except in the matter of [pronoun] [issue]. Impression: [[Provide a detailed narrative of the patient's mood disorder, including the nature and severity of symptoms such as depressive symptoms, anxiety, and functional impairment. Include relevant history such as trauma, substance use, and social instability. Discuss previous treatment attempts, focusing on the adequacy of antidepressant therapy trials and current medication regimen, noting any issues with polypharmacy, efficacy, and side effects. List differential diagnoses considered, such as major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder, and specify any diagnoses that have been ruled out, such as bipolar disorder or psychotic disorder.] For Example: Catharine presents with a chronic and severe mood disorder, characterized by persistent depressive symptoms, generalized anxiety, and functional impairment. Her history is complicated by significant trauma, substance use, and social instability. She has not previously received adequate trials of antidepressant therapy despite longstanding symptoms. Her current medication regimen is notable for polypharmacy, with limited efficacy and significant side effects. Differential diagnoses include major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. There is no evidence to support a diagnosis of bipolar disorder or psychotic disorder.] Predisposing, Precipitating, Perpetuating and Protective Factors: [[Provide a detailed analysis of factors affecting the patient's mental health. Include predisposing factors such as personal history and family background, precipitating factors like current life events, perpetuating factors that maintain the condition, and protective factors that support recovery. Use a narrative paragraph style to maintain consistency with the original content.] For Example: Predisposing factors include a history of childhood trauma, family discord, and parental divorce. Precipitating factors involve homelessness and social instability. Perpetuating factors include ongoing substance use, chronic pain, and housing instability, which contribute to her mental health challenges. Protective factors include her engagement with social and medical providers, sustained abstinence from crack cocaine and alcohol, and motivation for treatment.] Safety Assessment: [[Document the patient's current safety status, including any suicidal or homicidal ideation, self-harm behaviors, or risk to others. Include details about the patient's safety plan and any measures in place to mitigate risk.] For Example: Catharine denies suicidal or homicidal ideation. She reports a history of multiple suicide attempts but states that she is not experiencing thoughts of self-harm. She denies any history of hallucinations commanding harm to self or others. She expresses distress related to her living situation and social isolation but is engaged with her care team and has access to crisis support if needed. A safety plan is in place, with regular follow-up and monitoring by her care team.] Diagnoses: [[List the patient's diagnoses using appropriate OHIP code. Include a brief description of each diagnosis and its impact on the patient's health and functioning.] For example: 1. [Diagnosis 1] ([OHIP Code]): [Description] 2. [Diagnosis 2] ([OHIP Code]): [Description] ... [n. Diagnosis n] ([OHIP Code]): [Description] For example: 1. Persistent depressive disorder (OHIP Code): He reports chronic low mood, anhedonia, and functional impairment, with symptoms persisting for several years. 2. Schizoaffective disorder, depressive type (OHIP Code): He has a history of auditory perceptual disturbances and depressive symptoms, with partial response to antipsychotic and antidepressant therapy. 3. Generalized anxiety disorder (OHIP Code): He describes chronic anxiety, restlessness, and difficulty managing daily stressors, with partial response to fluoxetine.] Recommendations: - Biological (Medical and Physical): [Provide detailed recommendations related to medical and physical health.] 1. [Initiate new medication: Specify medication name, dosage, administration time, duration, and any repeats.] 2. [Discontinue medication: Specify medication name and reason for discontinuation.] 3. [Continue current medications: Specify conditions and ensure adherence to prescribed regimen.] 4. [Monitor for side effects and drug interactions: Consider specific patient history and current medications.] n. [And more] - Psychological: [Provide detailed recommendations related to psychological health.] 1. [Encourage participation in support groups and therapy: Specify type of support groups and therapy.] 2. [Facilitate engagement with cultural practices and community supports: Specify patient preferences.] n. [And more] - Sociocultural and Spiritual: [Provide detailed recommendations related to sociocultural and spiritual aspects.] 1. [Coordinate with housing and case management: Address housing instability and resource access.] 2. [Support applications for financial benefits: Specify benefits and ensure continuation.] 3. [Maintain regular follow-up with care providers: Specify types of providers.] 4. [Provide crisis support and safety planning: Specify conditions for support.] 5. [Arrange follow-up for medication monitoring: Specify frequency and purpose.] n. [And more] Follow-Up: [[Provide details about the follow-up plan, including timelines and next steps.] For example: - Schedule follow-up appointments to assess the effectiveness of medication changes and address any side effects. - Ensure ongoing communication with Catharine's care team to monitor her progress and adjust the treatment plan as necessary. - Continue to support her engagement with social services and housing resources to improve her living situation.] Thank you, again, for your referral of this patient. Yours sincerely, Sarah B. Danial, B.Sc., M.D., FRCPC, J.D. Consultant Psychiatrist