This is what the template looks like:

Fictional name

Date of Birth:

Date of Evaluation:

Identifying Info/Reason for Referral:

• Name, age, and race/ethnicity
• Who made referral and why?
• Who was present for the interview?

Presenting Problems:

• What are the 1-4 primary problems the client reports as the reason for their evaluation?

History if Present Illness (can use structured interviewing from DSM-5):

• What symptoms are presented (current and historical)?
• Describe symptoms, including duration, severity, impairment, and ages of onset
• What symptoms were denied or determined not to be present? (Make sure to cover behavior, anxiety, mood, and othersdiscuss all symptoms endorsed for each disorder, those not endorsed, and those not asked about).
• Current and history of suicidality, homicidality, and psychosis. Include dates and specific information regarding prior attempts/episodes.

History of Psychiatric Treatment:

• Has the client seen a psychiatrist or therapist? (If yes, describe course of treatment, dates, or ages and names of providers.)
• Has the client been administered any psychiatric medications? (If yes, describe course of treatment, dates or ages, names of medications, and if these were successful.)
• Has the client ever been a psychiatric inpatient? (If yes, describe.)
• Has the client ever expressed suicidal thoughts or have they ever attempted suicide? Describe each attempt and the date, location, and method used if the client ever attempted. Describe what was going on with the client.

Family History of Psychiatric Illness:

• Is there a family history of behavior, mood, anxiety, trauma, substance misuse, or other disorders in the parents, siblings, and second-degree relatives?

History of Substance Use/Abuse:

• Does the client currently use drugs or alcohol? Has the client used drugs or alcohol in the past? If yes, how much and how often? What was the age of first use, method of consumption, and length of current rate of use? Has the client ever received treatment for substance misuse? Does the patient have any legal history related to substance misuse?

Social History:

• With whom did the client grow up? Does the client have siblings? Briefly describe the client's relationship with family of origin.
• What is the client's marital history, including number and length of marriages and divorces?
• Does the client have children? If so, describe living arrangements for the children.
• Describe the client's education and employment.
• Have there been any family-based stressors recently (death, birth, moves, divorce, etc.)?
• Is there a history of military service?
• Does the client have a history of verbal, sexual, or physical abuse?
• Describe the client's support system (or lack thereof) and current methods of coping with stressors.
• Is there a history of legal problems for the client?

Medical History:

• Does the client have any current or past medical conditions or issues?
• Current non-psychiatric medications?
• Any history of hospitalizations?
• Any history of head injury?
• Any allergies?

Mental Status Exam:

• General appearance
• General behavior/style of interaction
• Speech, mood, affect, judgment/insight, orientation, cognition, thought content (delusions, hallucinations, paranoia, etc.), attention/concentration

Case Summary:

• Summarize the findings you presented above and make a good case for why you came to the diagnostic conclusions you present below. If you are still unclear about diagnosis, make sure you include rule-outs. Do not present new information in this sectionuse it as summary.

DSM-5 Diagnosis:

• Use ICD codes and the DSM-5 name for each disorder. Make sure to use these if you have no diagnosis (V71.09) or deferred.

Recommendations/Plan:

• What kind of treatment do you recommend?
• Does the client agree with treatment recommendations? If not, what have they decided?
• When will the client return to begin treatment?

Here is the video of the interview to answer the questions above:

https://youtu.be/-fSRsWj4hzU?si=AkidgsHshwkUBWqQ