Psych Evaluation

[YOUR COMPANY NAME]

Patient Information:

Name:
Date of Birth:
Gender:
Contact Information:

Date of Evaluation: [INSERT DATE]

Purpose of Evaluation:

This form provides a structured assessment for a comprehensive psychiatric evaluation, covering a broad spectrum of psychiatric dimensions.

Criteria:

The evaluation will systematically examine and record behavior patterns, mental state, symptoms, and history, providing a comprehensive mental health assessment.

Rating Scale:

1 = Poor
2 = Below Average
3 = Average
4 = Above Average
5 = Excellent

Assessment:

Criteria	Description	Rating Scale (1-5)
Behavior	Assess the patient's observable activities such as body movements.	1-5
Cognitive Ability	Evaluate cognitive functions of thinking, learning, and memory.	1-5
Emotion	Check degree of emotional responsiveness, including mood and feelings.	1-5
Psychiatric Symptoms	Assess signs of mental disorders and their severity.	1-5
Personal History	Analyze past experiences, family history, and environmental factors.	No rating
Risk Assessment	Evaluate risk of harm to self or others.	1-5
Treatment Plan	Outline proposed treatment plan based on evaluation findings.	Free-text
Follow-Up Plan	Recommendations for follow-up care, such as therapy or medication.	Free-text
Additional Comments	Any additional comments or observations.	Free-text

Overall Assessment:

A comprehensive summary of the patient's psychiatric state considering all the individual evaluations. (1-5)

Consent:

I, [Patient Name], consent to participate in this psychiatric evaluation and understand that the information provided will be used for assessment and treatment purposes. I understand that my privacy rights will be respected.

Signature:

Date: [Date Signed]

Signature:

Date: [Date Signed]