Psychiatric Evaluation Form

Note: This is a multi-page form.

Demographic Information

Name*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone (Home/Cell)

Phone (Work)

Email*

Employer

Occupation

School (for children, and adults when applicable)

Family Members

Name

First Name

Last Name

Relationship

Name

First Name

Last Name

Relationship

Emergency Contact Information

Name of Emergency Contact

First Name

Last Name

Phone

Relationship to Patient

Primary Medical Practitioner

First Name

Last Name

Phone

Permission to Contact Provider*

Yes No

Risk Assessment

Suicidal

Yes No

Frequency of Suicidal Thoughts

Comments

Homicidal

Yes No

Frequency of Thoughts

Comments

Medical/Behavioral History

Is Patient Currently Prescribed BH Meds?

Yes No

BH Medications prescribed

Please list medicine name, dosages, initial prescription and refill dates. Indicate whether patient is adhering to prescription.

Over the Counter Medications or Supplements

Past Psychiatric History

Psychiatric Hospitalizations

Yes No

Describe in Detail

Prior Outpatient Therapy

Please include previous practitioners, treatment dates, treatment interventions, etc.

For Physicians Only

Patient Name

First Name

Last Name

Recent Lab Test Results (if applicable)

Family Mental Health History

Substance Abuse History

CAFFEINE - Amount, Frequency, Duration

First Use

Last Use

Comments

TOBACCO - Amount, Frequency, Duration

First Use

Last Use

Comments

ALCOHOL - Amount, Frequency, Duration

First Use

Last Use

Comments

MARIJUANA - Amount, Frequency, Duration

First Use

Last Use

Comments

AMPHETAMINES - Amount, Frequency, Duration

First Use

Last Use

Comments

COCAINE - Amount, Frequency, Duration

First Use

Amount, Frequency, Duration

Last Use

Comments

OPIOIDS/NARCOTICS - Amount, Frequency, Duration

First Use

Last Use

Comments

HALLUCINOGENS - Amount, Frequency, Duration

First Use

Last Use

Comments

OTHER - Amount, Frequency, Duration

First Use

Last Use

Comments

Risk Factors

Check All That Apply*

Domestic Violence Child Abuse Sexual Abuse Eating Disorder Suicidal/Homicidal Ideation Prior Behavioral Health Inpatient Admissions

Other

Describe in detail

Diagnostic Impression

Axis I

Axis II

Axis III

Axis IV

Axis IV Level

Axis IV Level
	Select One
Mild	Axis IV Level: Mild (Select One)
Moderate	Moderate (Select One)
Severe	Severe (Select One)

Nature of Stressors

Nature of Stressors
	Select One
Family	Nature of Stressors: Family (Select One)
School	School (Select One)
Work	Work (Select One)
Health	Health (Select One)
Other	Other (Select One)

Current GAF

Highest GAF

Date

Physician's Name

First Name

Last Name

Signature

[clear]

Use your mouse or finger to draw your signature above

Psychiatric Evaluation Form

Demographic Information

Family Members

Emergency Contact Information

Onset, Duration, Intensity

Mental Status

Risk Assessment

Medical/Behavioral History

For Physicians Only

Substance Abuse History

Risk Factors

Diagnostic Impression