Psychiatric Evaluation Template

## What's Included

This Psychiatric Evaluation Template provides a comprehensive framework designed to capture all essential clinical information during an initial or follow-up psychiatric assessment. The template includes clearly defined sections such as Identifying Information, Chief Complaint, History of Present Illness, Past Psychiatric History, Medical History, Family Psychiatric History, Substance Use, Mental Status Examination, Risk Assessment (including suicidality and homicidality), Diagnostic Impressions, and Treatment Recommendations. Each section contains structured fields and prompts to ensure thorough, standardized data collection that supports diagnostic accuracy and treatment planning.

Additionally, the template incorporates symptom rating scales, medication reconciliation fields, and space for clinician observations and patient-reported outcomes. The Mental Status Examination segment guides clinicians through documenting appearance, behavior, mood, thought process, cognition, insight, and judgment. Risk assessments include checklists for self-harm and violence risk factors, ensuring safety concerns are explicitly addressed. This template facilitates clear, organized clinical notes that comply with documentation best practices and legal requirements.

## Who This Template Is For

This template is specifically designed for psychiatrists, clinical psychologists, psychiatric nurse practitioners, licensed clinical social workers, and other mental health professionals who conduct psychiatric evaluations and require a structured, evidence-based documentation tool to support clinical decision-making and continuity of care.

## How to Use

Begin by collecting patient identifying information and the chief complaint to frame the clinical encounter. Progress through the template sections methodically, using patient interviews, collateral information, and clinical observation to complete each field thoroughly. Document the History of Present Illness with attention to symptom onset, duration, severity, and functional impact. Use the Mental Status Examination prompts to systematically assess and record the patient's current cognitive and emotional state.

Incorporate relevant rating scales and risk assessment checklists to quantify symptom severity and safety concerns. Summarize diagnostic impressions based on DSM-5 or ICD-10 criteria, and outline a clear treatment plan including medications, psychotherapy referrals, and follow-up schedules. Review the completed evaluation for accuracy and completeness before integrating it into the patient’s electronic health record or printed clinical documentation.

## Customize with MentalNote

With MentalNote AI, clinicians can automatically generate fully customized psychiatric evaluation documents directly within Microsoft Word. By inputting key patient details and clinical data, MentalNote uses advanced natural language processing to populate the template sections with coherent, contextually appropriate narrative text—saving time while maintaining clinical precision. This integration allows mental health professionals to tailor each evaluation to their specific style and patient needs, ensuring consistent, high-quality documentation that enhances clinical workflow and supports optimal patient care.