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Psychiatric Evaluation Form Template

Streamline your mental health assessments effortlessly

Assessing mental health can be complex and overwhelming for professionals. This psychiatric evaluation template is designed specifically for mental health practitioners like you, ensuring thorough and effective evaluations. With clear, structured questions, it helps in diagnosing conditions, tracking patient progress, streamlining documentation, and enhancing communication with clients. Plus, it's WCAG-aligned for accessibility. Experience how straightforward evaluations can be by exploring the live template now.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone
Preferred contact method
Phone call
Text message
Email
Any
What brings you in today?
How long has this been a concern?
Less than 2 weeks
2-6 weeks
2-6 months
6-12 months
More than 1 year
Not sure
How much is this concern interfering with your life?
Not at all
A little
Moderately
A lot
Extremely
Not sure
Feeling down, depressed, or hopeless
Never
Rarely
Sometimes
Often
Always
Little interest or pleasure in doing things
Never
Rarely
Sometimes
Often
Always
Feeling nervous, anxious, or on edge
Never
Rarely
Sometimes
Often
Always
Trouble falling or staying asleep, or sleeping too much
Never
Rarely
Sometimes
Often
Always
Changes in appetite or weight
Never
Rarely
Sometimes
Often
Always
Difficulty concentrating
Never
Rarely
Sometimes
Often
Always
Periods of unusually high energy or needing little sleep
Never
Rarely
Sometimes
Often
Always
Hearing or seeing things that others do not
Never
Rarely
Sometimes
Often
Always
Distressing memories or nightmares about past events
Never
Rarely
Sometimes
Often
Always
Unwanted thoughts or repetitive behaviors you feel driven to perform
Never
Rarely
Sometimes
Often
Always
In the past month, have you had thoughts of suicide?
Yes
No
Prefer not to say
Do you have current intent or a plan to harm yourself?
Yes
No
Prefer not to say
Have you ever attempted suicide?
Yes
No
Prefer not to say
Thoughts about harming someone else
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Access to firearms or other lethal means at home
Yes
No
Prefer not to say
Alcohol use
Never
Rarely
Sometimes
Often
Always
In the past 3 months, have you used recreational drugs?
Yes
No
Prefer not to say
If yes or applicable, which substances have you used in the past 3 months?
Please Specify:
Have you ever been diagnosed with a mental health condition?
Yes
No
Not sure
Are you currently in mental health treatment (therapy or psychiatry)?
Yes
No
Current psychiatric medications (name, dose, frequency)
Medication allergies or adverse reactions
Prior psychiatric hospitalization
Never
Once
More than once
Not sure
Type your full name as acknowledgment
Date of acknowledgment
I consent to be contacted regarding this evaluation request
Yes
No
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Paper art illustration depicting a psychiatric evaluation form template with a pen and mental health symbols

When to use this form

Use this form during intake, pre-visit triage, or transitions of care to gather a clear picture of symptoms, risks, and supports. It suits outpatient clinics, hospital consults, school counseling, and telehealth. You can standardize presenting concerns, history, medications, substance use, and functioning, then route urgent cases fast. Pair it with the Mental health assessment form to broaden screening, and the DASS Form to track severity over time. For complex cases, repeat the form at follow-ups to show change and inform treatment plans.

Must Ask Psychiatric Evaluation Questions

  1. What brings you in today, and when did these symptoms start?

    This frames the chief concern and timeline, which guides prioritization and next steps. Clear onset and course help you separate acute issues from long-standing patterns.

  2. Have you had thoughts of harming yourself or others, and do you have a plan or intent?

    Direct risk questions surface immediate safety needs. Details about plan, means, and intent inform safety planning and escalation.

  3. What mental health and medical treatments have you tried, and what medications or therapies are you using now?

    Response history and side effects prevent repeating ineffective or risky options. Current regimens shape safe, coordinated decisions.

  4. How often do you use alcohol, cannabis, or other substances, and when was your last use?

    Substances can mimic or worsen symptoms and affect medication choices. Recency and frequency support accurate assessment and help anticipate withdrawal risks.

  5. Who do you live with, and what supports and stressors affect your day-to-day functioning?

    Context about housing, relationships, work, and school reveals risks and protective factors. If you need deeper context, add the Psychosocial assessment form to capture social history and resources.

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