Fillable Printable Psychiatric Evaluation Form - California

Psychiatric Evaluation Form - California

1 = OFFICE 2 = OTHER FIELD 3 = IF NON-FACE-TO-FACE 4 = HOME 5 = SATELLITE 6 = SCHOOL (LOC IS 1 IF NOT SPECIFIED)

ADULT PSYCHIATRIC EVALUATION

Confidential Patient Information

See W&I Code 5328

N AM E:

DOB:

CHART NO:

PROGRAM:

CLP013 (03/2010) Clinical Practice Page 1 of 2

Date: Time: Location: Service Type: MEDS VISIT

Face to Face:

Total Time:

Location:

Service Type: MEDS VISIT

IDENTIFYING DATA:

CHIEF COMPLAINT:

HX OF PRESENT ILLNESS:

PSYCHIATRIC HISTORY:

Inpatient:

Outpatient:

Past medications:

Current medications:

Suicidal/homicidal ideation/attempts:

Physical/Sexual abuse:

Substance abuse:

MEDICAL HISTORY: ies: Allerg

FAMILY HISTORY:

SOCIAL/CULTURAL HX:

1 = OFFICE 2 = OTHER FIELD 3 = IF NON-FACE-TO-FACE 4 = HOME 5 = SATELLITE 6 = SCHOOL (LOC IS 1 IF NOT SPECIFIED)

ADULT PSYCHIATRIC EVALUATION

Confidential Patient Information

See W&I Code 5328

N AM E :

DOB:

CHART NO:

PROGRAM:

CLP013 (03/2010) Clinical Practice Page 2 of 2

MENTAL STATUS: [WNL = Within Normal Limits]

Appearance/Hygiene:

WNL Disheveled Poor hygiene

Behavior:

WNL Uncooperative Poor eye contact Withdrawn Aggressive/agitated Intrusive Pacing

Talks/smiles/laughs to self Other (specify):

Speech:

WNL Rapid Pressured Loud Slow Soft Other (specify):

Mood/Affect:

WNL Depressed Angry/irritable Anxious Flat/blunted Tearful Constricted/restricted

Labile Other (specify):

Perceptual Process:

WNL Hallucinations: Auditory Command in nature Visual Other (specify):

Thought Process:

WNL Loose Tangential Circumstantial Flight of ideas Disorganized Thought blocking

Thought Content:

WNL Suicidal Ideation Homicidal Ideation

Delusions: Paranoid/persecutory Grandiose Religious Nihilistic Somatic Erotomanic

Insight:

Good Fair Poor

Memory: WNL Impaired: Immediate Recent Remote

Judgment:

Good Fair Poor

Oriented X 4 OR NOT Oriented to Person Place Time Situation

DIAGNOSTIC IMPRESSION (see Diagnosis form in chart for client's official diagnosis): “P” after principal diagnosis if not first on Axis I

AXIS I

AXIS II

AXIS III

AXIS IV

AXIS V Current GAF =

TREATMENT PLAN / RECOMMENDATIONS: