Psychiatric Intake Form for Mental Health Professionals (PDF & Word Doc)

A thorough psychiatric intake is the foundation of accurate diagnosis, appropriate treatment planning, and defensible clinical documentation. A well-structured intake form helps clinicians systematically gather the identification, medical, psychiatric, social, and safety information needed to formulate a diagnostic impression while ensuring nothing critical is missed during a new patient evaluation.

TherapyByPro’s Psychiatric Intake Form is a comprehensive, 16-page clinician-developed intake document designed specifically for psychiatrists, psychiatric nurse practitioners, and other prescribing mental health professionals conducting initial evaluations. Available as both a Word document and fillable PDF, the form guides clinicians through patient identification, current providers and referral information, a detailed psychiatric review of systems, medication history, sleep assessment, medical history and laboratory findings, substance use history, prior psychiatric treatment, family history, social and developmental history, a full safety assessment, standardized screening instrument tracking, a complete mental status examination, diagnostic impression, clinical decision-making, and an initial treatment plan.

The form opens with patient identification and emergency contact information, along with a structured section for documenting current treating providers and release of information status. A referral source and chief complaint section captures the precipitating event and history of the presenting problem in the patient’s own words. From there, a detailed psychiatric review of systems screens across mood, anxiety, psychotic, cognitive, neurovegetative, and behavioral symptom domains, with space for clinical notes on each item.

Subsequent sections document current medications, sleep patterns, vital signs and laboratory findings (including PDMP review and imaging), a substance-by-substance use history with AUDIT-C, CAGE, and DAST-10 scoring fields, prior psychiatric hospitalizations and outpatient treatment, a medication trial history table, and three generations of family psychiatric and medical history. A social history section addresses education, employment, living situation, legal history, trauma and adverse experiences, and current psychosocial stressors, followed by an optional developmental history section for child and adolescent patients.

What Is Included in This Psychiatric Intake Form

This comprehensive intake form includes documentation commonly used when conducting a new patient psychiatric evaluation:

• Patient Identification and Provider Coordination: Demographic information, legal status, guardianship, emergency contacts, and a table for documenting all current treating providers and ROI status.
• Referral and Chief Complaint: Referral source, referring provider details, and the history of the presenting problem including onset, severity, and functional impact.
• Psychiatric Review of Systems: A broad symptom checklist spanning mood, anxiety, psychotic, cognitive, eating, and attention-related symptom domains with a clinical notes column.
• Medication and Sleep History: Current medication documentation and a detailed sleep assessment including apnea, parasomnia, and nightmare history.
• Medical History and Labs: Vital signs, laboratory and diagnostic study tracking, PDMP review, imaging results, and a review of medical systems.
• Substance Use History: Substance-by-substance use tracking, nicotine and alcohol withdrawal history, standardized screening scores, and treatment history.
• Psychiatric Treatment History: Prior diagnoses, hospitalizations, outpatient treatment, and a detailed medication trial history table documenting response and reason for discontinuation.
• Family, Social, and Developmental History: Family psychiatric and medical history, social history, trauma and ACEs documentation, and an optional child/adolescent developmental history section.
• Safety Assessment: Structured suicidal and homicidal ideation screening, protective factors, weapons access, overall risk level, and safety plan documentation.
• Standardized Screening Instruments: A tracking table for PHQ-9, GAD-7, MDQ, ASRS, AUDIT-C, DAST-10, PCL-5, and C-SSRS scores.
• Mental Status Examination: A full MSE covering appearance, behavior, speech, mood, affect, thought process and content, cognition, insight, judgment, and reliability of information.
• Diagnostic Impression and Treatment Plan: DSM-5-TR diagnoses with ICD-10-CM codes, WHODAS 2.0 functional assessment, clinical formulation, medical decision-making, and an initial treatment plan with prescribing and follow-up documentation.

How This Psychiatric Intake Form Functions in Practice

This intake form is designed to be completed during a new patient psychiatric evaluation, providing a structured framework for gathering the clinical information necessary to reach a diagnostic impression and initial treatment plan.

• Before or During the Initial Visit: Structures the collection of identification, referral, medical, psychiatric, social, and family history information.
• Clinical Risk Documentation: Provides a dedicated safety assessment section covering suicidal ideation, homicidal ideation, means access, and protective factors.
• Diagnostic Support: Organizes review of systems, screening instrument scores, and mental status exam findings to support DSM-5-TR diagnostic formulation.
• Treatment Planning and Recordkeeping: Documents medical decision-making, medication trials, prescribing decisions, and follow-up plans as part of the clinical record.

Documentation Features

• Designed specifically for psychiatrists, psychiatric nurse practitioners, and prescribing mental health professionals.
• Sixteen pages covering identification through diagnostic impression and initial treatment plan.
• Includes a detailed psychiatric review of systems and full mental status examination.
• Provides structured tables for medication trials, substance use history, and family history.
• Includes a dedicated safety assessment section and standardized screening instrument tracker.
• Documents DSM-5-TR diagnoses with ICD-10-CM codes and WHODAS 2.0 functional assessment.
• Includes clinician and supervisor signature and attestation sections.

Practical Integration Notes

This form is intended to be completed by the evaluating clinician during a new patient psychiatric intake. Clinicians should supplement documented responses with direct clinical interview and customize sections as needed to reflect their practice setting, patient population, and applicable state and licensing board requirements. The completed intake should be maintained as part of the patient’s clinical record in accordance with HIPAA and applicable documentation standards.

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). Resource
• American Psychiatric Association. (2016). Practice Guidelines for the Psychiatric Evaluation of Adults (3rd ed.). Resource
• World Health Organization. (2010). WHO Disability Assessment Schedule (WHODAS 2.0). Resource
• Posner, K., et al. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings. American Journal of Psychiatry, 168(12), 1266–1277. Resource
• Substance Abuse and Mental Health Services Administration. Co-Occurring Disorders and Other Health Conditions. Resource
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. Resource