Psychiatry & Psychology
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<p>Psychiatric Evaluation, Initial</p><p>
<strong>Identifying Information:</strong></p><p>
[text name="variable_1" default="sample text"]is a[textarea name="variable_1" default="sample text"] year old
[checkbox name="variable_1" value="Caucasian|Latina|Latino|Latinx|African American|Asian American|mixed race"]
[checkbox name="variable_1" value="male|female|transgender male|transgender female|non-binary individual"] who presents
[checkbox name="variable_1" value="to outpatient treatment at SMFP|by telehealth"] for
[checkbox name="variable_1" value="initial psychiatric evaluation.|follow-up appointment."] </p><p><strong>History of Present Illness: </strong>
Current psychiatric dx: {{None|depression|anxiety|ADHD|bipolar disorder|OCD|PTSD}}
Current psychiatric medications: </p><p>
Current psychiatric provider: {{PCP|none}}</p><p><strong>CSPMP review: </strong> {{No patient data found|No concerns with review|per report: }}</p><p>
<strong>Reason for visit/Chief complaint:</strong></p><p>
<strong>Mood:</strong></p><p>
<strong>Anxiety:</strong></p><p>
<strong>Safety/suicidality/self-harm:</strong></p><p>
<strong>Sleep:</strong></p><p>
<strong>Appetite/eating:</strong></p><p>
<strong>Substance use:</strong></p><p>
<strong>Family/Social:</strong></p><p>

<strong>Previous psychiatric history:</strong>
BH Hosp:
Previous psychiatric diagnoses:
Previous medication trials:
Hx of outpatient treatment:
Psychiatric Providers:</p><p>
Therapy:</p><p>
Prior substance abuse treatment: </p><p>
History of self harm:
History of harm to others:</p><p><strong>Trauma history: </strong></p><p><strong>Developmental history:</strong>
Met developmental milestones on time.
Perinatal history normal</p><p>
<strong>Other concerns:</strong>
Legal Concerns:
Spiritual/Cultural Considerations:</p>
<p>Psychiatric Evaluation, Initial</p><p>
<strong>Identifying Information:</strong></p><p>
is ayear old

who presents
for
</p><p><strong>History of Present Illness: </strong>
Current psychiatric dx: {{None|depression|anxiety|ADHD|bipolar disorder|OCD|PTSD}}
Current psychiatric medications: </p><p>
Current psychiatric provider: {{PCP|none}}</p><p><strong>CSPMP review: </strong> {{No patient data found|No concerns with review|per report: }}</p><p>
<strong>Reason for visit/Chief complaint:</strong></p><p>
<strong>Mood:</strong></p><p>
<strong>Anxiety:</strong></p><p>
<strong>Safety/suicidality/self-harm:</strong></p><p>
<strong>Sleep:</strong></p><p>
<strong>Appetite/eating:</strong></p><p>
<strong>Substance use:</strong></p><p>
<strong>Family/Social:</strong></p><p>

<strong>Previous psychiatric history:</strong>
BH Hosp:
Previous psychiatric diagnoses:
Previous medication trials:
Hx of outpatient treatment:
Psychiatric Providers:</p><p>
Therapy:</p><p>
Prior substance abuse treatment: </p><p>
History of self harm:
History of harm to others:</p><p><strong>Trauma history: </strong></p><p><strong>Developmental history:</strong>
Met developmental milestones on time.
Perinatal history normal</p><p>
<strong>Other concerns:</strong>
Legal Concerns:
Spiritual/Cultural Considerations:</p>

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