New Patient Psychiatric Evaluation

PATIENT: [Full Name] DOB: [MM/DD/YYYY] | AGE: [##] | SEX: [M/F/Other] GENDER IDENTITY: [as reported] | PRONOUNS: [he/him / she/her / they/them] PREFERRED NAME: [if different] MRN: [___________] REFERRAL SOURCE: [Self / PCP / Therapist / ER / Insurance / Other: _____] REFERRING PROVIDER: [Name, credentials, practice] PRIMARY CARE PROVIDER: [Name, phone, fax] THERAPIST/COUNSELOR: [Name, phone — or "None identified"] INSURANCE: [Payer, plan, ID#] LEGAL STATUS: [Voluntary / Involuntary / Guardian — specify] INTERPRETER NEEDED: [No / Yes: Language _____, Mode: Phone/Video/In-person]

CHIEF COMPLAINT: [Patient's own words in quotes] // Example: "I've been depressed for months and my doctor said I should see a psychiatrist."

HISTORY OF PRESENT ILLNESS: [Patient Name] is a [age]-year-old [gender] with [no/a] prior psychiatric history, presenting for initial psychiatric evaluation with chief complaint of [CC]. ONSET: Symptoms began approximately [timeframe] ago. [Acute vs. gradual onset]. Precipitating factors: [life stressor / medical event / medication change / unknown]. COURSE: [Episodic / Persistent / Progressive / Fluctuating]. [Best period in past month]. [Worst period]. SEVERITY: Patient rates current [mood/anxiety/etc.] as [#]/10. [PHQ-9 score: ## — severity level]. [GAD-7 score: ## — severity level]. ASSOCIATED SYMPTOMS: Neurovegetative: [Sleep: ↑/↓/normal | Appetite: ↑/↓/normal | Energy: ↑/↓/normal] Cognitive: [Concentration: impaired/intact | Memory: concerns/intact] Psychomotor: [Agitation / Retardation / Normal] Hedonic: [Anhedonia present/absent] Somatic: [Headaches / GI / Pain / Other] FUNCTIONAL IMPACT: Work/School: [Unable to work / Decreased productivity / Missing ## days/month] Relationships: [Conflict / Withdrawal / Stable] Self-care: [Intact / Impaired — describe] ADLs: [Independent / Requires assistance] TREATMENT TO DATE: Prior medication trials: [See Past Psychiatric History] Current medications for psychiatric symptoms: [List or "None"] Current therapy: [Yes: type, frequency / No] Patient's response to prior treatment: [described in past psych hx] PATIENT'S GOALS FOR TREATMENT: "[Patient's own words]"

PSYCHIATRIC REVIEW OF SYSTEMS: [ MOOD ] Depressed mood: [+/-] Duration: [___] Anhedonia: [+/-] Hopelessness: [+/-] Worthlessness/guilt: [+/-] Elevated/euphoric mood: [+/-] // Screen for mania — see below Irritability: [+/-] Mood lability: [+/-] [ ANXIETY ] Excessive worry (GAD): [+/-] About: [___] Panic attacks: [+/-] Frequency: [___] Last episode: [___] Social anxiety: [+/-] Specific phobias: [+/-] Specify: [___] OCD symptoms: [+/-] Obsessions: [___] / Compulsions: [___] Health anxiety: [+/-] [ MANIA / HYPOMANIA ] Decreased need for sleep: [+/-] Grandiosity: [+/-] Racing thoughts: [+/-] Pressured speech: [+/-] Increased goal-directed activity: [+/-] Impulsivity/risk-taking: [+/-] Hypersexuality: [+/-] Duration of episodes: [___] // If any positive: assess for Bipolar I vs II vs cyclothymia [ PSYCHOSIS ] Auditory hallucinations: [+/-] Content: [___] Frequency: [___] Visual hallucinations: [+/-] Other hallucinations: [+/-] Specify: [___] Delusions: [+/-] Type: [paranoid/grandiose/somatic/other] Ideas of reference: [+/-] Thought disorganization: [+/-] Derealization: [+/-] Depersonalization: [+/-] [ TRAUMA / PTSD ] History of trauma: [+/-] Type: [combat/abuse/accident/other] — patient's words Intrusive memories/flashbacks: [+/-] Nightmares: [+/-] Avoidance: [+/-] Hypervigilance: [+/-] Emotional numbing: [+/-] PC-PTSD-5 score: [___/5] // Positive ≥3 [ SUBSTANCE USE ] See Section 5 — Substance Use History (separate detailed assessment) [ EATING ] Restriction/fasting: [+/-] Binge eating: [+/-] Purging behaviors: [+/-] Body image disturbance: [+/-] Current weight concerns: [+/-] [ COGNITIVE ] Memory complaints: [+/-] Word-finding difficulty: [+/-] Executive function: [+/-] Concentration: [+/-] MoCA/MMSE (if assessed): [___] [ SLEEP ] Insomnia (onset/maintenance/terminal): [+/-] Hypersomnia: [+/-] Sleep apnea (dx'd or suspected): [+/-] Nightmares: [+/-] Parasomnias: [+/-] [ SOMATIC ] Unexplained physical symptoms: [+/-] Pain (chronic): [+/-] Location: [___] GI symptoms: [+/-] Fatigue: [+/-] [ SELF-HARM / SUICIDALITY ] // Detailed assessment in Risk Section — document brief screen here Current SI: [+/-] History of attempts: [+/-] Current NSSI: [+/-]

PAST PSYCHIATRIC HISTORY: PRIOR DIAGNOSES: [List with approximate date of diagnosis] PSYCHIATRIC HOSPITALIZATIONS: [None / List: Hospital, Date, Duration, Reason, Voluntary/Involuntary, Discharge Rx] ER VISITS (psychiatric): [None / List: Date, Reason, Outcome] PARTIAL HOSPITALIZATION / IOP: [None / Program name, dates, completion status] OUTPATIENT TREATMENT HISTORY: [Prior psychiatrists/NPs: Names, approx. dates, reason for discontinuation] [Prior therapists: Names, modality, approx. dates] SUICIDE ATTEMPTS: [None / List each:] Date: [___] Method: [___] Medical severity: [ER/ICU/none] Precipitant: [___] Lethality: [low/moderate/high] Intent at time: [___] SELF-HARM (non-suicidal): [None / Type: ___, Frequency: ___, Last occurrence: ___, Currently active: Y/N] PRIOR MEDICATION TRIALS: // List ALL psychiatric medications — this protects you clinically and legally Drug | Dose | Duration | Reason Stopped | Response --------------|------------|------------|---------------------|------------------ [Medication] | [dose] | [duration] | [SE/ineffective/cost] | [helpful/not/partial] [Medication] | [dose] | [duration] | [reason] | [response] [Medication] | [dose] | [duration] | [reason] | [response] CURRENT PSYCHIATRIC MEDICATIONS (from prior provider): [List or "None"] PSYCHOTHERAPY HISTORY: [CBT / DBT / EMDR / Psychodynamic / Supportive / Other] Response: [helpful/partially helpful/not engaged]

SUBSTANCE USE HISTORY: [ ALCOHOL ] Current use: [None / Social / Regular — ## drinks/week] Pattern: [Daily / Weekends / Binge (≥4W/≥5M per occasion)] AUDIT-C Score: [___/12] // ≥3W/≥4M = positive screen Q1 (frequency): [0-4] Q2 (drinks/day): [0-4] Q3 (heavy drinking days): [0-4] CAGE-AID: [___/4] // ≥2 = clinically significant Cut down: [Y/N] Annoyed: [Y/N] Guilty: [Y/N] Eye-opener: [Y/N] Last drink: [___] Blackouts: [Y/N] Withdrawal hx: [Seizures: Y/N | DTs: Y/N | CIWA required: Y/N] Prior treatment: [AA / Detox / MAT — specify] [ CANNABIS ] Current use: [None / Y — frequency: ___, form: ___, potency: ___] Age of first use: [___] Method: [smoked/vaped/edibles] Last use: [___] Perceived benefit: [pain/sleep/anxiety/mood/other] [ STIMULANTS ] Cocaine/crack: [None / Y — frequency: ___, route: ___, last use: ___] Amphetamines (illicit): [None / Y — frequency: ___, last use: ___] Methamphetamine: [None / Y] [ OPIOIDS ] Prescription opioids (non-prescribed): [None / Y — drug: ___, freq: ___] Heroin: [None / Y — route: ___, last use: ___] Fentanyl (illicit): [None / Y] Overdose history: [None / Y — date(s), required naloxone: Y/N] Current MAT: [Buprenorphine / Methadone / Naltrexone — provider: ___] [ BENZODIAZEPINES / SEDATIVES ] Prescribed: [None / Y — drug: ___, dose: ___, prescriber: ___] Non-prescribed: [None / Y — source: ___, frequency: ___] [ TOBACCO / NICOTINE ] Current: [Never / Former (quit ___) / Current — PPD: ___, years: ___] NRT/cessation: [Y — product: ___ / N] [ OTHER ] Hallucinogens: [None / Y — substance: ___, last use: ___] Dissociatives (ketamine, PCP): [None / Y] Inhalants: [None / Y] Other: [___] SUBSTANCE USE DISORDER DIAGNOSES: [List or "None identified at this time"] IN RECOVERY: [N/A / Y — duration: ___, supports: ___] NALOXONE: [Prescribed: Y/N | Patient has access: Y/N | Education provided: Y/N]

PAST MEDICAL HISTORY: [Condition 1 — year diagnosed, current treatment] [Condition 2] [None reported / See PCP records] PAST SURGICAL HISTORY: [Procedure — year] [None] CURRENT MEDICATIONS (all): Drug | Dose | Frequency | Prescriber | Indication --------------------|-----------|-----------|-------------------|------------ [Medication] | [dose] | [freq] | [provider] | [reason] [Medication] | [dose] | [freq] | [provider] | [reason] OTC/Supplements: [List] ALLERGIES / ADVERSE REACTIONS: Drug: [Name] — Reaction: [___] — Severity: [mild/moderate/severe/anaphylaxis] NKDA (no known drug allergies) / NKA RELEVANT LABS (recent, if available): CMP: [date / values] CBC: [date / values] TSH: [date / value] Lipids: [date / values] HbA1c: [date / value] Other: [___] CARDIAC HISTORY: [None / Arrhythmia / QTc prolongation concern / HTN / Other] // Important for stimulants, antipsychotics, TCAs, lithium NEUROLOGICAL HISTORY: [None / Seizures / TBI / Migraines / Other] // Seizure history affects Wellbutrin, clozapine dosing; TBI affects all psychiatric Rx REPRODUCTIVE HEALTH (if applicable): PREGNANCY STATUS: [Not pregnant / Pregnant — GA: ___ weeks / Postpartum — ___ weeks] CONTRACEPTION: [None / Method: ___] // Critical for valproate, lithium, benzodiazepines, paroxetine counseling ENDOCRINE: Thyroid: [Normal/Hypothyroid/Hyperthyroid] Diabetes: [Y/N] HEPATIC/RENAL: [Normal / Impaired — affects medication dosing]

FAMILY PSYCHIATRIC HISTORY: Relative | Diagnosis | Medication Response / Notes ------------------|------------------------|------------------------------- Mother | [Depression/Bipolar/etc] | [Responded to sertraline / unknown] Father | [___] | [___] Sibling(s) | [___] | [___] Maternal side | [___] | [___] Paternal side | [___] | [___] Children | [___] | [___] FAMILY HISTORY OF SUICIDE: [None reported / Yes — Relationship: ___, Method: ___, Patient's age at time: ___] // Ask directly: "Has anyone in your family died by suicide?" FAMILY HISTORY OF SUBSTANCE USE DISORDER: [None / Yes — Relationship: ___, Substance: ___] FAMILY HISTORY UNKNOWN: [Adopted / Estranged / Unable to obtain]

SOCIAL HISTORY: [ LIVING SITUATION ] Housing: [Own home / Renting / With family / Homeless / Group home / Other] Stability: [Stable / At risk of eviction / Transitional] Household: [Lives alone / With partner / With children (ages: ___) / With parents] [ RELATIONSHIPS ] Relationship status: [Single / Partnered / Married / Divorced / Widowed] Quality: [Supportive / Conflicted / Isolated] Children: [None / Yes — ages: ___, custody: ___] Social support: [Strong / Limited / None identified] [ EDUCATION ] Highest level completed: [___] Currently enrolled: [Y/N] Field: [___] [ OCCUPATION ] Employment: [Full-time / Part-time / Unemployed / Disabled / Retired / Student] Occupation: [___] Work stress: [Low / Moderate / High — describe: ___] Currently on leave: [Y/N — FMLA/disability] [ FINANCIAL ] Insurance: [Commercial / Medicaid / Medicare / Uninsured] Financial stress: [None / Moderate / Significant] Medication cost concerns: [Y/N — addressed: ___] [ LEGAL ] Pending charges: [None / Yes — type: ___] Probation/parole: [None / Yes — PO: ___, conditions: ___] History of incarceration: [None / Yes — duration: ___] Restraining orders (as subject or recipient): [None / Yes] [ MILITARY ] Veteran: [Y/N] Branch: [___] Era: [___] Combat exposure: [Y/N] Deployment: [___] MST (military sexual trauma): [Declined to answer / None / Yes] Connected to VA: [Y/N] [ SPIRITUALITY / RELIGION ] Important to patient: [Y/N] Faith tradition: [___] Relevant to care: [___] [ CULTURAL BACKGROUND ] Ethnicity/cultural identity: [___] Cultural considerations for care: [___] Language preference: [___]

DEVELOPMENTAL HISTORY: [ CHILDHOOD ] Prenatal/birth complications: [None reported / ___] Developmental milestones: [Met on time / Delayed — specify: ___] Childhood behavioral issues: [None / ADHD symptoms / Conduct problems / Other] School performance: [Good / Average / Struggled — retained: Y/N] Special education services: [None / IEP / 504 — reason: ___] [ ADVERSE CHILDHOOD EXPERIENCES (ACEs) ] // Document sensitively — assess for trauma history Physical abuse: [Denied / Reported] Sexual abuse: [Denied / Reported / Declined to answer] Emotional abuse/neglect: [Denied / Reported] Household dysfunction: [Substance use in home: Y/N | DV: Y/N | Mental illness: Y/N] ACE Score (if assessed): [___/10] [ ADOLESCENCE ] First psychiatric symptoms: [Age: ___] Behavioral issues: [None / Conduct / Oppositional / Delinquency] Substance use onset: [Age: ___, Substance: ___] Sexual development: [Age-appropriate / Concerns: ___] [ RELATIONSHIPS / ATTACHMENT ] Primary attachment figure: [___] Quality of early attachment: [Secure / Insecure — describe: ___]

MENTAL STATUS EXAMINATION: [ APPEARANCE ] Age: [Appears stated age / Older / Younger] Build: [Average / Thin / Overweight / Obese] Grooming: [Well-groomed / Adequate / Disheveled / Malodorous] Dress: [Appropriate / Casual / Inappropriate — describe] Eye contact: [Good / Poor / Avoidant / Intense] Psychomotor: [No abnormalities / Agitated / Retarded / Tremor / Restless] [ BEHAVIOR ] Cooperation: [Cooperative / Guarded / Hostile / Evasive] Attitude: [Pleasant / Irritable / Suspicious / Seductive / Childlike] Rapport: [Good / Fair / Difficult to establish] [ SPEECH ] Rate: [Normal / Rapid / Slow] Volume: [Normal / Loud / Soft] Rhythm: [Normal / Pressured / Halting / Dysarthric] Fluency: [Fluent / Word-finding difficulty / Other] Amount: [Normal / Verbose / Terse] [ MOOD (Subjective) ] Patient reports: "[In their words — e.g., depressed, anxious, fine, frustrated]" [ AFFECT (Objective) ] Quality: [Euthymic / Depressed / Anxious / Irritable / Elevated / Dysphoric / Flat] Range: [Full / Restricted / Blunted / Flat / Labile] Intensity: [Normal / Heightened / Diminished] Appropriateness: [Congruent with thought content / Incongruent — describe] Mood-affect congruence: [Congruent / Incongruent] [ THOUGHT PROCESS ] [Linear, logical, goal-directed] OR [Circumstantial / Tangential / Loose associations / Flight of ideas / Thought blocking / Perseveration / Poverty of thought / Disorganized] [ THOUGHT CONTENT ] SI: [None / Active — see Risk Assessment] HI: [None / Active — see Risk Assessment] Obsessions: [None / Present — content: ___] Phobias: [None / Present — ___] Delusions: [None / Present — type: Paranoid / Grandiose / Somatic / Referential] Content: [___] Preoccupations: [None / Present — ___] [ PERCEPTUAL DISTURBANCES ] Hallucinations: [None] AH: [None / Present — command: Y/N / content: ___] VH: [None / Present — ___] Other: [Tactile / Olfactory / Gustatory / None] Illusions: [None / Present] Derealization/Depersonalization: [None / Present] [ COGNITION ] Level of consciousness: [Alert / Drowsy / Other] Orientation: [×4: person, place, time, situation / Disoriented to: ___] Attention/concentration: [Intact / Impaired — WFST: ___] Memory — immediate: [Intact / Impaired — digit span: ___] Memory — short-term: [Intact / Impaired — 3-word recall at 5 min: ___/3] Memory — long-term: [Intact / Impaired] Fund of knowledge: [Intact / Limited] Abstract reasoning: [Intact / Concrete] Formal cognitive testing: [Not assessed / MoCA: ___/30 / MMSE: ___/30] [ INSIGHT ] [Full — acknowledges illness and need for treatment] [Partial — acknowledges problems but not psychiatric illness] [Poor — denies illness or need for treatment] [Absent — no recognition of problems] [ JUDGMENT ] [Good — realistic assessment of situations, appropriate decisions] [Fair — occasional lapses in judgment] [Poor — consistent poor decision-making, impulsive behavior] [Impaired — describe: ___] [ INTELLIGENCE (estimated) ] [Average / Above average / Below average — based on: vocabulary, history, education]

RISK ASSESSMENT: [ SUICIDAL IDEATION — C-SSRS ] Current SI: [None / Passive / Active without plan / Active with plan / Active with intent] If present: Intensity: [Brief/transient / Intermittent / Persistent] Frequency: [Rare / Several times/week / Daily] Duration: [Seconds / Minutes / Hours] Controllability: [Can control / Cannot control] Deterrents: [Family / Religion / Fear of pain / None identified] Reasons: [Reasons for living > dying / Equivocal / Reasons for dying predominate] Ideation type: Passive death wish: [Y/N] "I wish I were dead" Non-specific active SI: [Y/N] "I want to kill myself" without method SI with method (no plan): [Y/N] SI with method and plan: [Y/N] Plan: [___] SI with intent: [Y/N] SI with intent and plan: [Y/N] [ SUICIDAL BEHAVIOR — LIFETIME & RECENT ] Preparatory behaviors (recent 3 months): [None / Giving away possessions / Researching methods / Obtaining means / Goodbye letters] Aborted attempt (lifetime): [None / Yes — date: ___, circumstances: ___] Interrupted attempt (lifetime):[None / Yes] Actual attempt (lifetime): [None / Yes — number: ___, most lethal: ___] Most recent attempt: [N/A / Date: ___, Method: ___, Outcome: ___] [ HOMICIDAL IDEATION ] HI present: [None] If present: Target: [Specific (name: ___) / Non-specific] Plan: [None / Present: ___] Means/access: [None / Yes: ___] Intent: [None / Present] Action taken: [Duty to warn assessed: Y/N | Tarasoff obligation: Y/N] [ RISK STRATIFICATION ] Static risk factors (historical): [ ] Prior suicide attempt [ ] Chronic psychiatric illness [ ] Family hx of suicide [ ] History of trauma/abuse [ ] Chronic pain/physical illness [ ] Male sex assigned at birth [ ] Age (>45 or adolescent) [ ] LGBTQ+ identity (minority stress) [ ] Access to firearms [ ] History of impulsivity/violence Dynamic risk factors (current, modifiable): [ ] Current SI/plan/intent [ ] Active substance use [ ] Hopelessness [ ] Recent major loss/stressor [ ] Recent psychiatric hospitalization [ ] Recent overdose [ ] Social isolation [ ] Insomnia [ ] Recent medication change [ ] Treatment non-adherence [ ] Active psychosis [ ] Ongoing domestic violence Protective factors: [ ] Reasons for living [ ] Engaged in treatment [ ] Future orientation [ ] Strong social support [ ] Religious/spiritual beliefs [ ] Children at home [ ] Fear of death/pain [ ] No access to means [ ] Therapeutic alliance [ ] Problem-solving ability [ MEANS RESTRICTION COUNSELING ] Firearms in home: [Y/N] If Y: counseling provided re: securing/removing: [Y/N] Medication access: [Secured / Unsecured] Limiting quantities discussed: [Y/N] Other means: [Counseling provided: Y/N] [ OVERALL RISK LEVEL ] ACUTE RISK: [Low / Moderate / High / Imminent] CHRONIC RISK: [Low / Moderate / High] [ CLINICAL REASONING FOR RISK LEVEL ] [Patient presents with [risk level] acute risk for self-harm based on: [List key contributing factors]. Protective factors noted include [list]. Disposition is [outpatient/higher level of care] because [reasoning]. Patient [does/does not) meet criteria for involuntary hold based on [state law, criteria].] [ SAFETY PLAN ] Completed: [Y/N — if N, reason: ___] Warning signs identified: [___] Internal coping strategies: [___] Social supports: [Names, phone numbers] Professional contacts: [Therapist: ___, After-hours line: ___] Crisis resources provided: - 988 Suicide & Crisis Lifeline (call or text 988) - Crisis Text Line: Text HOME to 741741 - Local ER: [Hospital name] - 911 instructions given: [Y/N] Safety plan document: [Given to patient / Uploaded to chart]

BIOPSYCHOSOCIAL FORMULATION: [ PREDISPOSING FACTORS ] Biological: [Genetic loading — FHx of ___; neurobiological vulnerabilities; medical comorbidities affecting brain: ___] Psychological: [Attachment style; early trauma; maladaptive schemas; temperament; cognitive style: ___] Social: [Adverse childhood experiences; poverty; discrimination; cultural factors; early relational trauma: ___] [ PRECIPITATING FACTORS ] What triggered this episode or this presentation: [Specific stressors, losses, life events, medication changes, substance use, medical events — with timeline] [ PERPETUATING FACTORS ] What is maintaining the problem: [Cognitive distortions; avoidance; social isolation; ongoing stressors; substance use; untreated medical conditions; lack of support: ___] [ PROTECTIVE FACTORS ] [Intelligence; motivation for treatment; social support; financial resources; spirituality; resilience; insight; employment: ___] [ DIAGNOSTIC SUMMARY ] [Patient Name] is a [age]-year-old [gender] presenting with a constellation of symptoms most consistent with [primary diagnosis]. The [duration] course, [characteristic features], and [ruling out alternatives] support this diagnosis over [differential]. Contributing factors include [predisposing] that created vulnerability, [precipitating] that triggered the current episode, and [perpetuating] factors that have maintained symptoms. Treatment prognosis is [good/fair/guarded] given [protective factors] balanced against [risk factors]. [ DIFFERENTIAL DIAGNOSIS CONSIDERED ] [Diagnosis 1] — Ruled out because: [___] [Diagnosis 2] — Ruled out because: [___] [Diagnosis 3] — Retained for monitoring: [___]

DIAGNOSES: [ PSYCHIATRIC — PRIMARY ] Axis I (DSM-5-TR): [F32.1] Major Depressive Disorder, moderate, single episode [F33.1] Major Depressive Disorder, moderate, recurrent [F41.1] Generalized Anxiety Disorder [F40.10] Social Anxiety Disorder [F41.0] Panic Disorder [F43.10] PTSD [F31.81] Bipolar II Disorder [F90.0] ADHD, Predominantly Inattentive [F20.9] Schizophrenia [F60.3] Borderline Personality Disorder // Delete inapplicable codes; add applicable ones [ SUBSTANCE USE DISORDERS ] [F10.20] Alcohol Use Disorder, moderate [F12.20] Cannabis Use Disorder, moderate [F11.20] Opioid Use Disorder, moderate [F14.20] Cocaine Use Disorder [ MEDICAL — RELEVANT ] [E11.9] Type 2 Diabetes Mellitus [I10] Essential Hypertension [E03.9] Hypothyroidism // List all comorbid medical conditions that affect psychiatric care [ PSYCHOSOCIAL / Z CODES ] [Z56.0] Unemployment [Z63.0] Relationship problems with spouse/partner [Z62.810] Personal history of physical abuse in childhood [Z91.19] Non-adherence to medical treatment [Z87.39] Personal history of other mental/behavioral disorders

TREATMENT PLAN: [ MEDICATION PLAN ] // Use the Risk/Benefit format for each medication decision ACTION: START [Medication] [Dose] [Frequency] Indication: [Diagnosis] — [FDA-Approved / Off-Label] Rationale: [Why this medication? Patient-specific factors, prior trial results, comorbidities, patient preference, formulary considerations] Risk/Benefit: Discussed risks including [specific side effects relevant to this patient]. Benefits of [symptom relief / functional improvement] outweigh risks. Patient understood and agreed to proceed. Questions answered. Monitoring: [What to monitor, when — labs, weight, BP, ECG, etc.] Instructions: [Take with/without food, timing, titration plan: ___] ACTION: START [Medication 2] [Dose] [Frequency] // Repeat for each medication started [ THERAPY REFERRAL ] [Not indicated at this time / Referred to: ___] Modality recommended: [CBT / DBT / CPT / EMDR / Psychodynamic / Supportive / Other] Rationale: [Why this modality for this patient/diagnosis] [ ADDITIONAL INTERVENTIONS ] Labs ordered: [CMP, CBC, TSH, lipids, HbA1c, other: ___] Referrals: [PCP for ___ / Neurology / Cardiology / Other: ___] Case management: [Not needed / Social work referral for: ___] Crisis resources: [988 / Safety plan completed] Sleep hygiene: [Discussed / Handout provided] Exercise recommendation: [30 min aerobic 3-5x/week — evidence for depression/anxiety] Psychoeducation: [Diagnosis education provided re: ___] Substance use: [SBIRT completed / Referred to: ___] [ FOLLOW-UP ] Next appointment: [Date / Timeframe: 2-4 weeks for new medications] Between-visit contact: [Patient may call ___ with concerns] Titration instructions: [If tolerated, increase [medication] to [dose] at [timeframe]] Red flags — when to seek immediate care: [Worsening SI / Manic symptoms / Severe medication side effects (rash, priapism, serotonin syndrome) / Psychotic symptoms / New neurological symptoms]

INFORMED CONSENT: Informed consent discussion was conducted with [patient / patient and family member: ___]. Patient demonstrated capacity to provide informed consent as evidenced by ability to understand, appreciate, reason, and communicate treatment decisions. For each medication prescribed, the following was discussed: MEDICATION: [Drug name] Indication & expected benefit: [Why this medication, what it should do] Common side effects discussed: [List specifically — e.g., nausea, sexual dysfunction, weight gain, sedation, dry mouth, etc.] Serious/rare risks discussed: [e.g., Serotonin syndrome with SSRIs; tardive dyskinesia with antipsychotics; Stevens-Johnson with lamotrigine; agranulocytosis with clozapine] FDA Black Box Warning: [Stated if applicable — e.g., suicidality in youth, increased mortality in elderly with dementia] Alternative treatments: [Other options presented: ___] Consequences of not treating: [Discussed: ___] Drug interactions: [Relevant interactions reviewed: ___] Pregnancy/reproductive risk: [Discussed if applicable: ___] Patient acknowledged understanding and agreed to proceed. Patient's questions: [Answered / No questions] TREATMENT AGREEMENT: [Signed treatment agreement obtained / verbal agreement obtained — copy in chart] Patient understands the following expectations: - Take medications as prescribed - Report side effects promptly - Disclose use of other substances/medications - Attend scheduled appointments - Contact office or go to ER if SI develops DOCUMENTATION OF CAPACITY: Patient demonstrated [intact / impaired] capacity as evidenced by: Understanding: [Able to restate diagnosis and treatment plan in own words] Appreciation: [Understands how treatment applies to own situation] Reasoning: [Able to weigh pros and cons of options] Communication: [Expressed clear preference]

PDMP REVIEW: Date/time accessed: [MM/DD/YYYY HH:MM] Database accessed: [State name PDMP — e.g., Florida PDMP / PMP InterConnect] Patient identity confirmed: [Name, DOB, address matched] RESULTS: [ ] No controlled substance prescriptions in the past [90/180] days — consistent with history [ ] Controlled substances found — consistent with patient-reported medications: [List: Drug, Dose, Qty, Prescriber, Date, Pharmacy — noting anything notable] [ ] Unexpected finding identified: [Describe: multiple prescribers / excessive quantities / dangerous combinations / drug not reported by patient — and clinical response taken] CLINICAL RESPONSE TO PDMP: [No action needed — findings consistent with clinical presentation] [Clinical conversation conducted regarding: ___] [Prescribing adjusted based on PDMP findings: ___] [Referral to addiction specialist due to: ___] // If controlled substance is being prescribed, this must be completed // If patient is new, document PDMP check even if no controlled substance prescribed today

URINE DRUG SCREEN: ORDERED: [Y — see orders / N — not clinically indicated at this time] RATIONALE: [New patient baseline / Controlled substance prescribing / Clinical suspicion / Routine monitoring per treatment agreement] PANEL: [Standard 10-panel / Extended panel / Specific drugs: ___] COLLECTION:[In-office observed / Lab send-out / Point-of-care] // If prior UDS results available: PRIOR UDS RESULTS: Date: [___] Results: [Negative / Positive for: ___] Expected substances present: [Y/N — patient on ___] Unexpected substances: [None / ___] Clinical response: [Discussed with patient / No action needed / ___]

BILLING INFORMATION: CPT CODE: [90791 — Initial psychiatric evaluation / 99205 — New patient, high complexity] TOTAL TIME: [Total face-to-face time: ## minutes] // Time-based billing: 90791 = 60-90 min typical; 99205 = 60-74 min MEDICAL DECISION MAKING (MDM) — for E&M billing: Problems addressed (supports complexity level): [ ] New problem — no established management plan (moderate-high) [ ] New problem with workup required (high) [ ] Chronic illness with severe exacerbation (high) [ ] Multiple comorbid psychiatric diagnoses (high) [ ] Psychiatric illness with medical comorbidities requiring coordination (high) Data reviewed: [ ] External records reviewed (prior records, collateral) [ ] Diagnostic test results reviewed (labs, prior assessments) [ ] Independent interpretation of diagnostic tests [ ] Discussed findings with interpreting provider Risk level: [ ] Prescription drug management (moderate-high) [ ] Drug requiring intensive monitoring (high — e.g., clozapine, lithium) [ ] Diagnosis or treatment significantly limited by social determinants [ ] Referral for hospital admission or emergency care discussed [ ] Controlled substance prescription (minimum moderate) SUPPORTING ELEMENTS DOCUMENTED: ✓ Comprehensive psychiatric history (multi-system review) ✓ Complete mental status examination ✓ Formal risk assessment with stratification ✓ Biopsychosocial formulation ✓ Multiple diagnoses addressed ✓ Medication management with risk/benefit discussion ✓ Safety planning completed ✓ Coordination with other providers (PCP, therapist) SUPERVISING PHYSICIAN (if applicable): [Collaborating physician: ___, MD/DO] [Attestation: Present / Reviewed and agree / Available for consultation]