Psychiatric Evaluation Template | Comprehensive Mental Health Assessment

The Psychiatric Evaluation: The Foundation of Treatment

A comprehensive psychiatric evaluation is the cornerstone of psychiatric care. Unlike a therapy session focused on a specific concern, a psychiatric evaluation is a systematic assessment designed to understand the patient holistically: their presenting psychiatric symptoms, their medical history, their family psychiatric history, their substance use, their medical medications and any interactions, their psychosocial functioning, and their risk factors. From this foundation, the psychiatrist develops a differential diagnosis, formulates the case, and initiates a treatment plan.

The evaluation document becomes the north star for treatment — it's referenced at every subsequent visit, it guides medication choices, and it tracks progress from baseline. A thorough evaluation prevents diagnostic errors, identifies comorbid conditions, and ensures that treatment is targeted and evidence-based.

What is a psychiatric evaluation?

A psychiatric evaluation is a comprehensive clinical assessment that synthesizes information across multiple domains to formulate a diagnostic impression and treatment plan. It includes chief complaint, history of present illness, past psychiatric history, medical history, medications, substance use history, family history, social history, review of systems, mental status examination, risk assessment, and diagnostic impression and plan.

The evaluation serves both as an initial document and as a reference point for ongoing care — it establishes baselines, identifies all active diagnoses, and documents informed consent for treatment.

What goes in the template

A standard psychiatric evaluation includes:

Demographics & Chief Complaint: Date of evaluation, patient name/DOB, age, gender, race/ethnicity, primary language, contact information. Chief complaint: what brought the patient to psychiatry in their own words or as referred by a provider.

History of Present Illness (HPI): Narrative chronology of the current psychiatric episode or concern. When did symptoms begin? What was happening in their life? How have symptoms evolved? What has made them better or worse? How are symptoms affecting functioning (work, relationships, sleep, appetite)? Are there triggers or precipitants? What is their insight into the problem?

Past Psychiatric History: All prior diagnoses, hospitalizations, crisis visits, medication trials, therapy experiences. For each psychiatric episode: onset, severity, treatment received, response to treatment, duration, full or partial remission. Are there prior suicide or self-harm attempts? Any restraining orders or legal involvement related to psychiatric symptoms?

Substance Use History: Current and past use of alcohol, cannabis, stimulants, opioids, hallucinogens, or other substances. Frequency, quantity, age of onset, periods of abstinence, impact on functioning, treatment for substance use disorder, withdrawal symptoms. Document if patient is in recovery and supports in place.

Medical History: All significant medical conditions, surgeries, chronic illnesses. Are there medical conditions that could cause or complicate psychiatric symptoms? Thyroid disease, autoimmune conditions, cardiovascular disease, neurological conditions, pain syndromes?

Current Medications: All psychiatric and non-psychiatric medications, dosages, frequency, duration. Any known allergies or adverse reactions? Any over-the-counter, herbal, or supplemental products? Are there potential drug-drug interactions?

Family Psychiatric History: Psychiatric diagnoses in first-degree relatives (parents, siblings, children): depression, bipolar disorder, schizophrenia, anxiety, substance use disorder, suicide. Age of onset, treatment response, severity. Psychiatric history in extended family when relevant.

Social History: Educational attainment, occupational history, current employment status, financial stability, housing security, legal history, trauma history. Who is in their life — spouse/partner, children, close relationships? Are relationships stable or in crisis? What are their strengths and values?

Review of Systems: Screen for symptoms of depression (sleep, appetite, energy, mood, concentration, hopelessness, guilt), anxiety (worry, panic, phobias, avoidance), mania (grandiosity, decreased need for sleep, racing thoughts, impulsivity, risky behavior), psychosis (hallucinations, delusions, disorganized thinking), trauma responses (flashbacks, nightmares, hypervigilance), and physical symptoms that might have psychiatric or medical underpinnings.

Mental Status Examination (MSE):

• Appearance: Grooming, hygiene, appropriate dress, visible signs of distress or unusual appearance
• Behavior: Psychomotor activity (agitation, retardation, restlessness), aggression, cooperation, eye contact, mannerisms
• Speech: Rate (fast, slow), volume (loud, quiet), coherence, organization, unusual speech patterns
• Mood: How the patient describes their emotional state ("I feel depressed," "Anxious," "Angry")
• Affect: What you observe (congruent with mood, flat, labile, blunted, restricted, inappropriate)
• Thought Process: Coherent and goal-directed vs. tangential, loose, pressured, flight of ideas, circumstantial
• Thought Content: Delusions, obsessions, preoccupations, suicidal or homicidal ideation
• Perception: Hallucinations (auditory, visual, tactile, olfactory, gustatory)
• Cognition: Orientation (person, place, time, situation), memory (immediate, recent, remote), attention, concentration
• Insight: Does the patient recognize they have a psychiatric problem and that treatment is needed?
• Judgment: Are they capable of sound decisions about their care and safety?

Risk Assessment: Suicide risk (current ideation, intent, plan, access to means, prior attempts, protective factors). Homicide risk (thoughts of harming others, access to weapons, history of violence). Risk of self-harm, elopement (if inpatient), or vulnerability to exploitation. Who is safe? Who is at risk?

Diagnostic Impression: What are the primary diagnoses? Use DSM-5 criteria. Rule out medical causes, substance-induced disorders, and other psychiatric differentials. Diagnostic formulation: how do these diagnoses fit together? Is there a unifying explanation, or are there separate diagnoses?

Formulation & Etiology: Biopsychosocial conceptualization: What biological factors (genetics, brain chemistry, medical illness) contribute? What psychological factors (trauma, cognitive patterns, coping)? What social factors (stressors, support, safety)? What is the most likely cause or combination of causes of the patient's presentation?

Prognosis: What is the likely course of the untreated illness? What is the likely response to treatment? What factors predict good vs. poor prognosis?

Treatment Plan & Recommendations:

• Medication: Which psychiatric medications are recommended? Dosage, frequency, rationale, expected timeline for benefit, side effects to monitor, labs/monitoring needed
• Psychotherapy: Is therapy recommended? What modality (CBT, supportive, psychodynamic)? Frequency?
• Hospitalization: Is inpatient care needed, or is outpatient safe with adequate support?
• Referrals: Other specialists, groups, community resources
• Safety Planning: Specific plans if patient is suicidal or homicidal
• Follow-up: When will the patient be seen again? What will be assessed at that visit?

Informed Consent: Document that the patient understands the diagnoses, the recommended treatment, the risks and benefits, and alternatives. Did they consent? Are there capacity concerns?

Signature & Credentials: Psychiatrist or qualified clinician, credentials, date.

When to use a psychiatric evaluation

• Initial psychiatric care: Any new patient presenting to psychiatry
• Diagnostic clarification: When diagnosis is unclear and comprehensive assessment is needed
• Treatment-resistant symptoms: Reassessing all factors that might affect treatment response
• Medication management initiation: Baseline for medication trials
• Hospitalization intake: Required for all psychiatric hospitalizations
• Court-ordered evaluation: Legal/forensic evaluations
• Disability determinations: Social Security, workers' compensation, or other benefit evaluations
• Pre-surgical clearance: Psychiatric risk assessment before major medical procedures

How to use the psychiatric evaluation template with Scriber

During evaluation: You conduct the comprehensive assessment, asking questions across all domains, documenting responses, and completing the mental status examination. You make note of key findings as you go: presenting symptoms, medical contributions, past treatment responses, current stressors. The session is recorded.

After evaluation: When you transcribe with Scriber, the full evaluation interview is captured — all the history you gathered, the MSE observations you made, the diagnostic thinking. Scriber's clinical AI can extract:

• Demographic information and chief complaint
• Full psychiatric, medical, substance use, and family histories
• MSE findings across all domains
• Risk assessment data
• Differential diagnoses and reasoning
• Diagnostic formulation
• Prognosis and treatment recommendations
• Medication suggestions with rationale

Your evaluation document auto-generates with all sections populated from the session transcript. You review, make edits as needed, and have a comprehensive, thorough evaluation. No starting from a blank template.

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Download the Psychiatric Evaluation Template — PDF and DOCX formats available. Use during evaluation to guide assessment or complete after using the structured format.

Start a 7-day trial — Record your psychiatric evaluation, Scriber transcribes the comprehensive assessment, and auto-generates an evaluation document with all history, MSE findings, diagnoses, and treatment plan sections.