A psychiatric evaluation is the full first assessment: the history, a mental status exam, a risk formulation, the diagnosis, and the plan. Copy the free template, see two filled examples, and check what each section needs, from past medication trials to the safety plan.
Blank psychiatric evaluation template
FreePSYCHIATRIC EVALUATION Patient: [Name] Date of birth: [Date] Date of evaluation: [Date] Setting: [Outpatient, inpatient, emergency, or telehealth] Clinician: [Name, credentials] IDENTIFYING INFORMATION Identifying data: [Age, gender, living situation, work or school] Referral source: [Who referred, and the question they are asking] Sources of information: [Patient, family or others with consent, records reviewed] Reliability: [How reliable the history seems, and why] CHIEF COMPLAINT In the patient's words: [Reason for the evaluation, quoted] HISTORY OF PRESENT ILLNESS Onset and course: [When symptoms began, triggers, and how they have changed] Current symptoms: [Mood, anxiety, sleep, appetite, energy, concentration, psychosis] Mania or hypomania screen: [Past or current elevated or irritable mood, less need for sleep, risky behavior] Functioning: [Work, school, relationships, self-care] Stressors: [Losses, conflict, health, money, legal] Treatment so far: [What has been tried for this episode, and the response] PAST PSYCHIATRIC HISTORY Previous diagnoses: [Diagnoses, and who made them] Hospitalizations: [Number, years, reasons, voluntary or involuntary] Medication trials: [Each medication with dose, duration, response, side effects, and why stopped] Psychotherapy: [Type, duration, what helped] Suicide attempts and self-harm: [When, method, intent, medical care needed] Violence: [Aggression, weapons, legal consequences] SUBSTANCE USE Alcohol: [Amount, frequency, last use; AUDIT-C or other screen] Cannabis: [Form, amount, frequency] Other substances: [Type, route, frequency, last use] Tobacco and nicotine: [Type and amount] Withdrawal and treatment: [Withdrawal seizures or delirium, past treatment, periods of abstinence] MEDICAL HISTORY Medical conditions: [Including thyroid, neurological, cardiac, head injury, seizures] Current medications: [All medications with doses, including over-the-counter and supplements] Allergies: [Drug and other allergies, with reactions] Reproductive health: [Pregnancy, postpartum, or contraception, when relevant] FAMILY PSYCHIATRIC HISTORY Relatives affected: [Mood, anxiety, psychotic, and substance use disorders, and suicide, with the relationship] Treatment response in family: [Medications that helped relatives] SOCIAL HISTORY Upbringing and development: [Childhood, education, trauma] Current situation: [Relationships, children, work or school, money, housing] Supports: [Family, friends, community, faith] Legal: [Current or past legal issues] MENTAL STATUS EXAM Appearance: [Grooming, dress, apparent age] Behavior: [Eye contact, engagement, psychomotor activity, abnormal movements] Speech: [Rate, volume, tone, fluency] Mood: [In the patient's words] Affect: [Range, intensity, stability, congruence with mood] Thought process: [Linear, circumstantial, tangential, or disorganized] Thought content: [Preoccupations, obsessions, delusions, suicidal or homicidal ideation] Perception: [Hallucinations, and whether responding to internal stimuli] Cognition: [Alertness, orientation, attention, memory; screening score if done] Insight: [Understanding of the illness and the need for treatment] Judgment: [As shown by recent decisions] RISK ASSESSMENT Suicidal ideation: [Passive or active, frequency, intent, plan, preparation] Screening tool: [Such as the C-SSRS, with result] Risk factors: [Past attempts, recent loss, substance use, hopelessness, impulsivity] Protective factors: [Reasons for living, supports, engagement in care, future plans] Access to lethal means: [Firearms, stockpiled medications, other means, and what was agreed] Violence risk: [Thoughts of harming others, target, history, access to weapons] Risk formulation: [Acute and chronic risk, low, moderate, or high, with your reasoning] Safety plan: [Warning signs, coping steps, contacts, means safety, emergency steps] DIAGNOSTIC IMPRESSION Formulation: [Biological, psychological, and social factors that explain the presentation] Diagnoses: [Primary and other diagnoses, with specifiers] Differential: [Other diagnoses considered, including medical and substance causes] PLAN Medications: [Start, change, or continue, with dose, rationale, and the consent discussion] Psychotherapy: [Type, frequency, referral] Labs and monitoring: [Baseline labs, ECG, rating scales to repeat] Safety: [Safety plan, means safety, level of care] Coordination: [Primary care, therapist, family involvement with consent] Follow-up: [When, with whom, and when to seek help sooner] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient psychiatry, new referral from primary care
34-year-old woman, works full time in an office, lives with her partner. Referred by her family physician for diagnosis and treatment advice for low mood. Sources: the patient and the referral letter; a reliable historian. Chief complaint: “I’ve felt flat and exhausted for over two months, and I can’t focus at work.”
Low mood for about 10 weeks, starting after a restructuring at work doubled her workload. Lost interest in running and seeing friends. Wakes at 4 a.m. most nights and can’t get back to sleep. Poor appetite, with 3 kg (7 lb) of weight loss since her last primary care visit, per the referral. Low energy, poor concentration, and guilt about falling behind. Missed 4 days of work in the last month. PHQ-9 today 19. No past or current periods of elevated or irritable mood, less need for sleep, or risky behavior. No psychotic symptoms or panic attacks. No treatment yet.
No previous psychiatric diagnoses, hospitalizations, or medication trials. Saw a counselor for 6 sessions as a student after a bereavement, which helped. No suicide attempts, self-harm, or violence.
Alcohol: 1 to 2 glasses of wine on 2 or 3 nights a week, up from weekends only, to help her sleep; AUDIT-C 3. No cannabis, other drugs, or tobacco. Hypothyroidism, on levothyroxine 75 mcg daily; TSH normal 6 months ago. No other medications. No known drug allergies. Uses an IUD; not pregnant.
Mother treated for depression, with a good response to sertraline. No family history of bipolar disorder, psychosis, or suicide. Grew up with both parents; no childhood trauma reported. University degree. Partner of 6 years is supportive. No children, no legal issues.
Appearance: casually dressed, well groomed, looks tired. Behavior: cooperative, reduced eye contact, mild psychomotor slowing, no abnormal movements. Speech: soft and slow, fluent. Mood: “flat and worn out.” Affect: constricted, sad, congruent; tearful when discussing work. Thought process: linear and goal-directed. Thought content: guilt about work; passive thoughts of death, no suicidal intent or plan; no homicidal ideation or delusions. Perception: no hallucinations. Cognition: alert and oriented; attention mildly reduced. Insight and judgment: good.
Passive thoughts of not wanting to be alive, a few times a week for 3 weeks. No active ideation, intent, plan, preparation, or past attempts. C-SSRS screen positive for passive ideation only. Risk factors: depressive episode, insomnia, hopelessness at times, more alcohol. Protective factors: supportive partner, reasons for living, no past attempts, seeking treatment. No firearms at home; only a small supply of medications. No thoughts of harming others. Risk formulation: low acute risk; it would rise with active ideation, heavier drinking, or a major loss. Safety plan written together and a copy given; her partner knows the plan, with her consent.
Major depressive disorder, single episode, moderate. Depressed mood and loss of interest for 10 weeks, with sleep, appetite, energy, concentration, and guilt symptoms, passive thoughts of death, and clear impairment at work. No history of mania or hypomania; no psychotic features. Hypothyroidism is treated; TSH to be rechecked. Drinking rose after the mood change and worsens sleep, but is not the main driver. Adjustment disorder is less likely, given the number and severity of symptoms.
Start sertraline 50 mg daily. Discussed benefits, common side effects, 4 to 6 weeks to full effect, and to report worsening mood or new suicidal thoughts at once; she agrees. Referral for CBT. TSH and CBC. Advised stopping alcohol while depressed; sleep routine discussed. Safety plan in place: call 911 or go to the nearest emergency department if suicidal thoughts get stronger or she feels unsafe. Letter to her family physician. Follow-up in 2 weeks, with a PHQ-9 at each visit.
Outpatient psychiatry, referral for diagnostic clarification
22-year-old man, engineering student, lives with his parents. Referred by his nurse practitioner after two antidepressants helped little and one left him “wired.” Question: is this bipolar disorder? Sources: the patient, his older sister by phone with his consent, and pharmacy records. Reliable. Chief complaint: “I crash for weeks, and sometimes I’m the opposite.”
Low mood for 6 weeks, with oversleeping, low energy, poor concentration, and withdrawal from friends. PHQ-9 16. Describes two past spells, at 19 and 21, of 5 to 6 days with 4 hours of sleep a night without tiredness, fast speech, many new projects, and spending about $1,500 he couldn’t afford. Both happened off medication and without drug use. Kept attending classes; no hospitalization or psychosis. His sister confirms both spells and that the family noticed the change. MDQ positive.
Depressive episodes at 18 and 20, treated in primary care. Sertraline up to 100 mg for 10 weeks: partial response. Escitalopram 10 mg for 3 weeks: stopped after he felt restless and irritable and slept 5 hours a night; settled within days of stopping. Six sessions of CBT, helpful. No hospitalizations, suicide attempts, self-harm, or violence.
Cannabis on weekends, 1 or 2 joints, for 2 years; none during the high spells, by his and his sister’s account. Alcohol 4 to 6 drinks a month. Vapes nicotine daily. No other drugs. No medical conditions, regular medications, or known drug allergies. TSH and CBC normal 2 months ago, per primary care.
Maternal uncle with bipolar disorder, treated with lithium. Mother has depression. No family history of suicide. Normal development; no trauma reported. Third year of his degree; grades drop during low spells. Close to his sister, with a few good friends. No legal issues. No firearms at home.
Appearance: casually dressed, adequate grooming. Behavior: cooperative, good eye contact, slowed but not agitated. Speech: normal rate, low volume, not pressured. Mood: “low, but not as bad as last month.” Affect: mildly restricted, reactive, congruent. Thought process: linear. Thought content: no delusions; passive thoughts of death in the past 2 weeks, none today; no homicidal ideation. Perception: no hallucinations. Cognition: alert, oriented, attention intact. Insight: fair; sees the high spells as his “best times.” Judgment: fair.
Passive thoughts of death a few times in the past 2 weeks, none today. No intent, plan, preparation, or past attempts. Risk factors: likely bipolar disorder, family history of mood disorder, cannabis use, impulsive spending when high. Protective factors: close sister, future plans, engaged in care, no access to firearms. No thoughts of harming others. Risk formulation: low acute risk; chronic risk higher than average, given the likely diagnosis. Safety plan written; he agreed to share it with his sister.
Bipolar II disorder, current episode depressed, moderate. Two past hypomanic episodes meet criteria by history and collateral: at least 4 days of less need for sleep, fast speech, more activity, and overspending, noticed by others, without marked impairment or psychosis. The reaction to escitalopram settled quickly once stopped, so it doesn’t count toward the diagnosis, though it is consistent with it. Differential: recurrent major depression, unlikely given the hypomania; substance-induced mood disorder, unlikely as the spells happened without drug use; ADHD, unlikely as the symptoms come in episodes; borderline personality disorder, unlikely as his mood shifts last days, not hours.
Diagnosis and reasoning explained; education on bipolar disorder given. No antidepressant on its own, given the hypomania. Options discussed: quetiapine, lamotrigine, or lithium. He chose lamotrigine, to avoid the weight gain and sedation he worried about with the others, and understands it takes several weeks to reach a working dose: 25 mg daily for 2 weeks, then 50 mg daily for 2 weeks, then 100 mg daily, toward a usual target of 200 mg daily. Told to stop it and seek care the same day for any rash, especially with fever or mouth sores. Daily mood and sleep chart; regular sleep times; cut down cannabis. Referral for psychotherapy, such as CBT or interpersonal and social rhythm therapy. Safety plan in place: call 911 or go to the nearest emergency department if he feels unsafe. Letter to his nurse practitioner. Follow-up in 2 weeks.
The story of this episode: how it started, how it has changed, and what it has cost the patient.
Avoid: Listing symptoms without a timeline. The diagnosis often depends on when each symptom began and how long it lasted.
Everything before this episode, in enough detail to guide the next treatment choice.
Avoid: “Tried several antidepressants.” Two weeks at a starting dose is not the same as a failed full trial.
What you observed during the interview, domain by domain. It is the objective core of the evaluation.
Avoid: A normal exam pasted from a template. Record what you saw today, especially anything that doesn’t fit the history.
Your structured judgment about the risk of harm to self or others, and what you are doing about it.
Avoid: “Denies SI” as the whole assessment. A screening answer is not a formulation of risk.
The diagnosis, and the reasoning that links the history and exam to it.
Avoid: A diagnosis with no supporting criteria. Say which symptoms, and for how long, meet it.
Treatment, safety, and follow-up, with the reason behind each choice.
Avoid: Starting a medication without recording the consent discussion and what to watch for.
Before starting an antidepressant, ask about past spells of high or irritable mood, little need for sleep, and risky behavior, and ask family when you can. An antidepressant alone can trigger hypomania or mania.
Record each trial’s dose, duration, response, and side effects. Without them, the next prescriber can’t tell an inadequate trial from a true non-response.
A single word like “low” doesn’t show your thinking. Name the risk and protective factors you weighed, and what would change your judgment.
Thyroid disease, other medications, sleep problems, and substance use or withdrawal can all look like a primary psychiatric illness. Record what you considered and what you checked.
Family members and old records often change the diagnosis. Say who told you what, and note the patient’s consent to the contact.
Vero Scribe writes the evaluation in your template from the interview, with the patient’s consent, or from your dictation. You review the history, the mental status exam, and the risk formulation, edit them, and copy the note into your EHR.
The reason for referral and the history of present illness; past psychiatric, substance, medical, family, and social history; a mental status exam; a risk assessment; the diagnosis with your formulation; and the plan. The template follows that order.
The evaluation is the full first assessment that sets the diagnosis and the plan. Later progress notes focus on what changed: target symptoms, side effects, risk, and medication decisions.
Record what you asked about ideation, intent, plan, and past behavior; the risk and protective factors; access to lethal means; your judgment of risk with the reasons; and the safety plan. A tool such as the C-SSRS supports the assessment but doesn’t replace it.
When you can, yes. Collateral often changes the diagnosis, especially when bipolar disorder is in question. Note the patient’s consent, and label which information came from whom.
Yes. Record that the visit was by video, where the patient was, and an emergency contact, and note in the mental status exam what you could and couldn’t observe on screen.
Yes. Copy it, or download it as a Word or text file. No account needed.
Follow-up and medication management visits, tracked by target symptoms, side effects, and risk.
Initial assessments, follow-ups, and consultation letters, drafted from the visit.
What belongs in the history of present illness, with examples.
A multi-problem example, and how to tie each problem to its plan.
Notes, documents, and follow-up in one workspace.
The codes used most often in psychiatry.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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