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Run: Psychiatric Intake Documentation

Psychiatric Intake Documentation template for recording presenting concerns, psychiatric history, risk screening, mental status exam findings, provisional di...

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Intake Overview

Patient Identifier (required)

Enter the internal medical record number or other approved patient identifier. Do not enter SSN.

Intake Date (required)

Intake Time (required)

Care Setting (required)

Referral Source (required)

Chief Concern (required)

Briefly describe the presenting concern in the patient's or referral source's words.

Consent and Disclosure

Consent for Psychiatric Evaluation and Treatment (required)

Confirm that the patient or authorized representative has consented to the evaluation and documentation of clinical information.

Yes No N/A

Privacy Notice Acknowledged (required)

Confirm acknowledgment of the applicable privacy notice and permitted use of PII/PHI for treatment, payment, and operations.

Yes No N/A

Authorized Representative Present? (required)

Representative Relationship

Psychiatric History

Prior Psychiatric Diagnosis

List prior diagnoses only if known and clinically relevant.

History of Psychiatric Hospitalization (required)

Hospitalization Details

Include facility, approximate date, and reason for admission if known.

Current Psychiatric Medications

List current medications, dose, and adherence if known.

Prior Treatment History

Current Symptoms and Risk

Current Symptoms (required)

Symptom Duration

Suicidal Ideation (required)

Homicidal Ideation (required)

Risk Details

Document plan, intent, means, protective factors, and any immediate safety actions taken.

Substance Use Concern (required)

Mental Status Exam

Appearance (required)

Behavior (required)

Speech (required)

Mood (required)

Affect (required)

Thought Process (required)

Thought Content

Include delusions, obsessions, preoccupations, or other clinically relevant content.

Perception (required)

Orientation (required)

Provisional Diagnosis and Level of Care

Provisional Diagnosis (required)

Enter the working diagnosis and, if used, the ICD-10 code.

Recommended Level of Care (required)

Level of Care Rationale (required)

Explain how symptoms, risk, functional impairment, and supports informed the recommendation.

Immediate Follow-Up Plan

Include referrals, safety planning, medication plan, or next appointment if applicable.

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