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Compliance and documentation

Your guide to documenting an initial psychiatric evaluation (with a template)

Save time with a psychiatry evaluation template that organizes patient data, reduces stress, and helps to ensure accurate documentation.

November 21, 2025 • Updated on April 17, 2026

By Dr. Juli Fraga, Psy.D

11 min read

By Dr. Juli Fraga, Psy.D

Writing a psychiatric evaluation is an important part of clinical care. Your evaluation will document crucial details about your patient’s presenting concern(s), psychiatric history, medical history, and psychosocial functioning.

Knowing what to include in your initial evaluation can feel overwhelming. Prescribers often worry about missing critical details that could affect diagnosis or risk assessment. As with psychiatric treatment plans, there’s not one standard template to guide you. 

Read on to learn how to document an initial psychiatric evaluation. We’ll show you what information to include and common challenges to look out for. We’ll also provide a template to help streamline the process and meet your documentation needs.

Key insights

1

An initial psychiatric evaluation should include the most important details about your patient and their presenting concern(s), health history, medication use, and psychosocial functioning. Aim to keep your evaluations clear, objective, prompt, and succinct, including only the details that are relevant to diagnosis and treatment.

2

Headway supports psychiatrists with resources like documentation templates and AI-assisted notes, so administrative work never gets in the way of patient care.

How should an initial psychiatric evaluation run?

The initial psychiatric evaluation sets the stage for treatment planning, goal setting, and clinical care. While this appointment helps you collect crucial clinical data, it’s also an opportunity to build rapport. 

Some patients may feel vulnerable about disclosing their mental health symptoms. You can help put them at ease by letting them know what to expect during the appointment. Patients often feel more comfortable when they feel understood, seen, and cared for. Expressing a desire to help and empathizing with your patient’s distress helps build a strong provider-patient relationship, which correlates with positive treatment outcomes.

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What are the requirements for documenting initial psychiatric evaluations?

A comprehensive psychiatric evaluation should include detailed information about your patient’s presenting concern and medical history. Here’s a comprehensive list of information to include:

  • Demographic information: Include identifying information, such as date of birth, gender, race/ethnicity, address, insurance information, contact information, and an emergency contact person. 
  • Treatment team: Include all mental health and medical providers involved in the patient’s care.
  • Current medications: Document each medication that your patient is taking and briefly explain why each medication was prescribed, as well as the response to current medications. Additionally, assess for adherence to medication. 
  • Known drug allergies: Document any known drug allergies.
  • Psychiatric history: Include information and date ranges on previous mental health treatment, hospitalizations, or higher levels of care, such as substance use treatment or intensive outpatient programs. Document any current or past thoughts of harm to self or others, as well as your patient’s current (and prior) psychiatric diagnoses.
  • Past psychiatric medication: Include information about any past psychiatric medication(s), including dosage(s), any reported side effects, and why the medication was stopped. 
  • Medical history: Include a medical history, including any past surgeries, hospitalizations, and chronic or current illnesses.
  • Substance use history: Include any current or past substance use.
  • Family history: Include any pertinent information, including family history of mental or medical concerns. Examples include a family history of high blood pressure, heart disease, or depression.
  • Social history: Your patient’s social history includes their current relationship status, social support, work history, and any difficulties forming or maintaining relationships. If your patient is a minor or a student, include school information as well. Also include any information about past trauma (e.g., child abuse or neglect) and any reported loss (e.g., pregnancy loss or death of a family member). 
  • Any other pertinent information: Include any other pertinent information that’s important for your patient’s care. 
  • Diagnostic formulation: Write an assessment of the patient's presentation, including all supporting symptoms and duration to meet required diagnostic criteria for each diagnosis. Include any pertinent rule-outs as you get to know the patient.
  • Justification for medical necessity: Support your justification for the level of treatment service, frequency, duration, and modality.
  • Plan: Plot out a course of treatment, with information about medication initiation, adjustment, labs, non-medication interventions, or transfer to alternative level of care.

A psychiatry evaluation template you can customize

Here’s the template that Headway providers use to document psychiatric intakes. It makes documentation easier by covering all of the crucial clinical information you need to proceed with treatment.

Patient information

Patient name: 

DOB: 

Address: 

Age: 

Sex: 

Relationship status: 

Occupation:

Contact information: 

Emergency contact: 

Insurance information: 

Date of evaluation: 

Evaluator: 


General

Chief complaint:


Presenting symptoms

History of present illness: 


Psychiatric review of symptoms

Depressive symptoms

[ ] Yes

[ ] No, denies post or present symptoms


Anxiety symptoms

[ ] Yes

[ ] No, denies post or present symptoms


Trauma-related symptoms

[ ] Yes

[ ] No, denies post or present symptoms


Manic/hypomanic symptoms

[ ] Yes

[ ] No, denies post or present symptoms


Psychotic symptoms

[ ] Yes

[ ] No, denies post or present symptoms


Past psychiatric history


Any prior psychiatric diagnoses?

[ ] Yes

[ ] No, denies prior psychiatric diagnoses


Any prior psychiatric treatment?

[ ] Yes

[ ] No, denies prior psychiatric treatment


Any prior psychiatrist hospitalizations?

[ ] Yes

[ ] No, denies prior psychiatric treatment


Any psychiatric medication history?

[ ] Yes

[ ] No, denies prior psychiatric treatment


Alcohol and substance use

Select which of the following apply:


Alcohol

[ ] Endorses [ ] Denies [ ] Not selected


Tobacco/nicotine

[ ] Endorses [ ] Denies [ ] Not selected


Cannabis

[ ] Endorses [ ] Denies [ ] Not selected


Hallucinogens

[ ] Endorses [ ] Denies [ ] Not selected


Opioids

[ ] Endorses [ ] Denies [ ] Not selected


Methamphetamine

[ ] Endorses [ ] Denies [ ] Not selected


Other

[ ] Endorses [ ] Denies [ ] Not selected


Social, developmental, and family history

Social history:


Developmental history:


Trauma history:


Psychiatric family history:


Other providers

Are there other relevant providers with whom the patient is collaborating?


[ ] Primary care physician

[ ] Other mental health providers

[ ] Other medical providers


Please provide details:


Medical history

Allergies:

Active medications at start of session:

Medical conditions:

Vital signs:

Relevant test results:

Results of C-SSRS:


Risk assessment

Suicidal ideation

[ ] Denies suicidal ideation

[ ] Wish to be dead with thoughts of suicide

[ ] Ideation without intent or plan

[ ] Intent

[ ] Plan

[ ] Access to means

[ ] Other


Self harm

[ ] Denies urge to self-farm

[ ] Urges without plan or intent

[ ] Intent

[ ] Recent self-harm behaviors

[ ] Other


Homicidal ideation

[ ] Denies homicidal ideation

[ ] Ideation without intent or plan

[ ] Identified victim

[ ] Intent

[ ] Plan

[ ] Access to means

[ ] Other


Violent/destructive behavior

[ ] Denies urges for violent/destructive behavior

[ ] Urges without plan or intent

[ ] Identified victim

[ ] Intent

[ ] Plan

[ ] Recent violent or destructive acts

[ ] Other


Additional relevant information:


History of harm

History of self harm

[ ] Endorses [ ] Denies [ ] Not selected


History of suicidal ideation

[ ] Endorses [ ] Denies [ ] Not selected


History of suicide attemps

[ ] Endorses [ ] Denies [ ] Not selected


History of harm to others

[ ] Endorses [ ] Denies [ ] Not selected


History of violent/destructive behavior

[ ] Endorses [ ] Denies [ ] Not selected


Other

[ ] Endorses [ ] Denies [ ] Not selected


Protective and risk factors

Static risk factors/static liabilities:


Modifiable risk factors/modifiable liabilities:


Protective factors/strengths:


What actions have been taken to minimize risk, if any?


What is the patient’s current overall, acute risk of harm to themselves or others?

[ ] Low [ ] Moderate [ ] High


Safety plan:


Mental status exam

Attention:

Orientation:

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought process:

Thought content:

Memory:

Judgement:

Insight:


Assessment and plan

Diagnostic formulation:


Justification for medical necessity:


Plan:

An example initial psychiatric evaluation

Patient information

Patient name: Sarah M. Thompson

DOB: 05/14/1993

Address: 1240 NE Irving Street, Portland, OR 97232

Age: 32

Sex: Female

Relationship status: Single

Occupation: Marketing Manager

Contact information: (503) 555-2874 | [email protected]

Emergency contact: Emily Thompson (sister) – (206) 555-9138

Insurance information: Blue Cross Blue Shield of Oregon – PPO Plan

Date of evaluation: 11/06/2025

Evaluator: Rebecca Chang, PMHNP-BC


General

Chief complaint:

“I’ve been feeling down and anxious for months and can’t seem to get back to normal.”

Presenting symptoms:

Low mood, decreased energy, poor concentration, early morning awakening, excessive worry, muscle tension, and irritability.

History of present illness:

The patient is a 32-year-old female who presents with a 6-month history of worsening depression and anxiety. She reports difficulty getting out of bed in the mornings, loss of interest in previously enjoyable activities, and persistent feelings of guilt and worthlessness. Anxiety manifests as excessive worry about work performance and finances, accompanied by restlessness and muscle tension. Denies panic attacks. Denies any current or past suicidal ideation, though she occasionally wonders “if things will ever get better.” She attributes symptom onset to work-related stress and a recent breakup. No psychotic or manic symptoms reported.


Psychiatric review of symptoms

Depressive symptoms

☑ Yes

Anxiety symptoms

☑ Yes

Trauma-related symptoms

☐ Yes

☑ No, denies past or present symptoms

Manic/hypomanic symptoms

☐ Yes

☑ No, denies past or present symptoms

Psychotic symptoms

☐ Yes

☑ No, denies past or present symptoms


Past psychiatric history

Any prior psychiatric diagnoses?

☑ Yes — Generalized Anxiety Disorder diagnosed at age 27

Any prior psychiatric treatment?

☑ Yes — brief course of outpatient CBT in 2021

Any prior psychiatric hospitalizations?

☑ No, denies prior psychiatric hospitalization

Any psychiatric medication history?

☑ Yes — previously prescribed sertraline 50 mg daily (discontinued after 6 months due to side effects of nausea)


Alcohol and substance use

Alcohol

☑ Endorses — drinks socially (1–2 glasses of wine on weekends)

Tobacco/nicotine

☐ Endorses

☑ Denies

Cannabis

☐ Endorses

☑ Denies

Hallucinogens

☐ Endorses

☑ Denies

Opioids

☐ Endorses

☑ Denies

Methamphetamine

☐ Endorses

☑ Denies

Other

☐ Endorses

☑ Denies


Social, developmental, and family history

Social history:

Lives alone in an apartment. Employed full-time as a marketing manager. Maintains supportive friendships and close contact with family. No legal or financial issues.

Developmental history:

Normal prenatal, birth, and developmental milestones. Describes childhood as stable and supportive.

Trauma history:

Denies history of abuse or major traumatic events.

Psychiatric family history:

Mother with history of depression; paternal uncle with alcohol use disorder.


Other providers

Are there other relevant providers with whom the patient is collaborating?

☑ Primary care physician — Dr. Lisa Morales

☐ Other mental health providers

☐ Other medical providers

Please provide details:

Primary care physician manages general medical care and referred patient for psychiatric evaluation.


Medical history

Allergies:

No known drug allergies.

Active medications at start of session:

Multivitamin daily.

Medical conditions:

Mild seasonal allergies; otherwise healthy.

Vital signs:

BP 118/74 mmHg, HR 76 bpm, RR 16/min, Temp 98.4°F, BMI 23.4

Relevant test results:

No abnormal findings reported by PCP.

Results of C-SSRS:

Denies suicidal ideation or behavior.


Risk assessment

Suicidal ideation

☑ Denies suicidal ideation

Self harm

☑ Denies urge to self-harm

Homicidal ideation

☑ Denies homicidal ideation

Violent/destructive behavior

☑ Denies urges for violent/destructive behavior

Additional relevant information:

No history of aggression or self-harm behaviors.


History of harm

History of self harm

☐ Endorses

☑ Denies

History of suicidal ideation

☐ Endorses

☑ Denies

History of suicide attempts

☐ Endorses

☑ Denies

History of harm to others

☐ Endorses

☑ Denies

History of violent/destructive behavior

☐ Endorses

☑ Denies

Other

☐ Endorses

☑ Denies


Protective and risk factors

Static risk factors/static liabilities:

Family history of mood disorder; female gender.

Modifiable risk factors/modifiable liabilities:

Work-related stress, lack of exercise, social isolation during depressive episodes.

Protective factors/strengths:

Insightful, help-seeking, stable employment, supportive family and friends, no substance misuse.

What actions have been taken to minimize risk, if any?

Referral to therapy, initiation of medication management, discussion of safety planning, and provision of crisis resources.

What is the patient’s current overall, acute risk of harm to themselves or others?

☑ Low

Safety plan:

Patient agrees to contact emergency services or crisis hotline if suicidal thoughts emerge; will reach out to therapist or trusted family member for support.


Mental status exam

Attention: Alert and attentive.

Orientation: Fully oriented to person, place, time, and situation.

Appearance: Well-groomed, casual attire, appropriate for setting.

Behavior: Cooperative and engaged, normal psychomotor activity.

Speech: Normal rate, rhythm, and tone.

Mood: “Down but hopeful.”

Affect: Constricted but congruent with mood.

Thought process: Linear, logical, goal-directed.

Thought content: No delusions, obsessions, or suicidal ideation.

Memory: Intact short- and long-term recall.

Judgment: Good.

Insight: Fair to good; recognizes symptoms and need for treatment.


Assessment and plan

Diagnostic formulation:

32-year-old female presenting with symptoms consistent with Major Depressive Disorder, single episode, moderate, and Generalized Anxiety Disorder. No evidence of psychosis, mania, or acute safety risk.

Justification for medical necessity:

Symptoms significantly impair daily functioning and occupational performance. Ongoing psychiatric evaluation and management are necessary to reduce symptom burden and prevent deterioration.

Plan:

  • Initiate escitalopram 10 mg daily.
  • Refer for weekly cognitive behavioral therapy.
  • Encourage sleep hygiene, exercise, and structured routine.
  • Provide education on SSRI side effects and expected timeline for improvement.
  • Follow up in 4 weeks or sooner if worsening mood or emergence of suicidal thoughts.

Billing for psychiatric evaluations

Code 90792 is used to bill insurance payers for an intake evaluation, often referred to as a “psychiatric diagnostic evaluation.” Code 90792 can only be billed by a medical professional like a psychiatrist or psychiatric nurse practitioner. 

Here’s how the American Medical Association defines 90792 in the official CPT codebook.

CPT code 90792: Psychiatric diagnostic evaluation (with medical services)

Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies.

Common challenges with psychiatry evaluation documentation

It’s not uncommon to run into challenges when writing an evaluation. Prescribers want to protect their patient’s confidentiality while also providing all of the necessary information for insurance reimbursement. 

Here’s a list of common challenges and tips to overcome each one. 

Time management 

Evaluation writing can be very time-consuming, especially if you’re not sure what to include. With your patient’s permission, consider taking notes during the session. This ensures you don’t miss important details. And as a Headway provider, you can use our templates to streamline the process.

Organization 

Patients don’t always report their symptoms and histories succinctly. They may not remember every detail of their medical history or family life. Feelings of embarrassment may prevent patients from disclosing substance use struggles or relationship difficulties. 

  • Follow your patient’s lead to build rapport. Some patients may want to discuss their family life or work history before answering your questions or talking about their current symptoms. 
  • When patients feel nervous about the evaluation, it can be helpful to begin the interview by asking about their past psychiatric care and social history. Patients may feel more comfortable discussing these topics before they disclose their current symptoms.  
  • Ask follow-up questions and explain your rationale (e.g., I’d like to ask about your social support; this information will help me develop your care plan).

Information selection 

Knowing what information to include can feel confusing, even when you’re using a template. Ask yourself, “Does this information add diagnostic or prognostic value? Does it impact treatment planning?” If the answer is “no,” the information may not be needed. When in doubt, consult with a colleague. 

Brevity 

Lengthy evaluations can be time-consuming for other providers (and insurers) to read. Try writing short snippets that include objective facts. Concision also helps maintain your time management.

Tips for writing effective and compliant progress notes for psychiatry sessions

  • Be clear: Using a template or following a format can help you write a clear evaluation. Try to avoid jargon-filled language, as this makes your evaluation easier to understand and follow. 
  • Be objective: Include the facts and avoid clinical interpretations. Your interpretations and case conceptualization should be reserved for the patient’s treatment plan and progress notes. 
  • Be prompt: Complete your evaluation as soon as possible. Many insurance payers require prescribers to complete documentation within 72 hours of the intake appointment. Prompt documentation ensures that insurance payers will reimburse for services and can help avoid delays.
  • Be specific: When including any information not obtained from the patient, specify the source.

Explore more psychiatry support resources from Headway

Mental health providers are always learning, even years after their training ends. To further your continuing education, Headway has a wide library of resources for providers. Check out these articles to start.

Psychiatric practice support resources:

How Headway supports prescribing providers:

Streamline your practice with Headway

Writing a comprehensive psychiatric evaluation lays down the foundation for clinical care. With Headway, you don’t have to spend hours on this administrative task. Our platform provides templates, tools, and workflows to help you spend more time on direct patient care. Learn more about how Headway supports psychiatrists.

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

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