Psychiatry Intake Form

The Psychiatry Intake Form is purpose-built for psychiatric medication management practices, capturing the comprehensive psychiatric history that psychiatrists and psychiatric nurse practitioners need for diagnostic assessment and pharmacologic treatment planning. This template collects patient demographics alongside a detailed psychiatric symptom review covering mood disorders (depression, mania, hypomania), anxiety disorders (generalized anxiety, panic, social anxiety, OCD, PTSD), psychotic symptoms (hallucinations, delusions, disorganized thinking), ADHD symptoms, eating disorder screening, and personality disorder features. Each symptom domain includes onset, severity, and functional impact.

Designed for general psychiatry, psychopharmacology, consultation-liaison, forensic psychiatry, and addiction psychiatry practices, this form includes sections for psychiatric medication history (all prior trials with dosages, durations, reasons for discontinuation, and side effects), psychiatric hospitalization history, ECT or TMS treatment history, substance use assessment (type, quantity, frequency, last use, withdrawal history), and detailed family psychiatric history. The safety assessment section screens for current and past suicidal ideation, suicide attempts, self-harm, homicidal ideation, and access to means.

All fields are HIPAA-compliant and designed with the psychiatric evaluation workflow in mind. The comprehensive pre-visit documentation allows the psychiatrist to review the full medication trial history, identify patterns of treatment response, and arrive at the consultation prepared to discuss diagnostic impressions and medication recommendations. The safety screening ensures that high-risk patients are identified before the first appointment, allowing for appropriate safety planning.