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]
Evaluation Templates @ Template.net
