Psych Eval pre-submission form

Psychiatric Evaluation Case Presentation Form

Please complete the form below to schedule your appointment for psychiatric medication management.
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which is your primary Jade Wellness Center Location:
Primary therapist

Other
Level of Care

Other
Reason for Psychiatric Evaluation
Please provide information as to why you are seeking psychiatric services including referral source and treating condition.
Have you attended an individual appointment with your primary therapist
Date of last therapy appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease indicate the date of your last individual..
Please note: You must attend an individual counseling session with your primary therapist before a psychiatric evaluation can be scheduled.

Kindly contact your primary therapist to arrange this appointment. Your request for a psychiatric evaluation will be denied until this requirement is met.

Please do not procedure with this form any further.
Current or Past Concerns:
Please specify the reason for your visit and current psychiatric symptoms
Please provide chief complaint / reason for visit
Have you been treated for Mental Health services in the past?
Please provide details on previous treatment for mental health. Provide information regarding provider, dates and treatments.

Diagnosis/Concern

Rows	Now	Past	Never	Comments
Depression
Anxiety
Mood Disorder
Anger Management
Bipolar Disorder
Suicidal Ideations or Attempts
Paranoia / Hallucination
Schizophrenia
Eating Disorder
Trauma or PTSD
Emotional/Verbal Abuse
Sexual Abuse
Physical Abuse
Attention Deficit Disorder
Obsessive Compulsive Disorder
Autism
Relationship Distress / Marital Issues

Current Medications:

Please list current medications

Rows	Medication	Dosage/Frequency	Condition	Prescriber
1
2
3
4
5
6
7
8
9
10

Please list PAST medications prescribed for mental health treatment

Rows	Medication	Dosage/Frequency	Condition	Prescriber
1
2
3
4
5
6
7
8
9
10

Medical
Do you have any current physical problems or concerns?
If yes, please specify concerns:
Past or current medical issues:

Medical issues

Rows	Current	Past	Details
Heart Problems
High or Low Blood Pressure
Stroke
Cancer (Type)
Arthritis
Epilepsy
Diabetes
Anemia
Kidney Problems
Eye / Ear Problems
Liver Conditions
Lung/Breathing Problems
Thyroid Conditions
Sexually Transmitted Disease(s)
Other:

Previous Surgeries:
If yes, specify
Previous Hospitalizations:
If yes, specify:
Screening
Past attempts to harm self or others:
Comments:
Past attempts to harm self or others
Current Risk of Harm to Self:
Comments
Current Risk to Harm Self
Current Risk of Harm to Others
Comments:
Current Risk of Harm to Others
Assessments:

PHQ-9 / GAD-7 / ASRS

Over the last 2 weeks, how often have you been bothered by the following problems?

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)

Over the last 2 weeks, how often have you been bothered by the following problems?

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)

Adult ADHD Self Report

Rows	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you are expected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Calculation
Family History

Important Family Members

Rows	Name	Relationship	Age	Check if live in same household
1.
2.
3.
4.
5.
6.
7.
8.

Have you or anyone in your family experienced the following?

Rows	Self	Family	Comments
Anxiety
Panic Attacks
Bipolar Disorder
Depression
Suicidal ideations/attempts
Hallucinations
Paranoia
Schizophrenia
Thoughts of harming self
Physical Abuse
Attention Deficit

Additional Information:
Current living environment:
Who are you living with and where?
Do you have history of legal charges or charges pending?
Specify Legal History
Include history of charges and dates.
Work History
Please list current employment and any long-term previous employment
Educational/School History
Please list highest level of education and any secondary education.
History of Overdose?
Date of last overdose?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is there fire arms in your home?
Do you have any other access to fire arms?
Do you have children?
If yes, how many and who do they reside with?
Are you on disability/ssi?
Basic Needs Met? (Food, Clothing Shelter)
If no, specify
Provide information about unmet needs
Do you use Nicotine?
The information contained in this form is confidential. The content of this form, which may include one or more attachments, is strictly confidential, and is intended solely for the use of Jade Wellness Center. If you are not the intended recipient, you cannot use, copy, distribute, disclose or retain the infromation or any part of its contents or take any action in reliance on it.
Should be Empty:

Psychiatric Evaluation Case Presentation Form

Current or Past Concerns:

Current Medications:

Medical

Past or current medical issues:

Screening

Assessments:

Family History

Additional Information: