PATIENT NAME: [PATIENT'S NAME]
AGE: [PATIENT'S AGE]
ROOM NUMBER: [ROOM NUMBER]
REFERRING CLINICIAN: [REFERRING CLINICIAN'S NAME]
CONSULTING SPECIALIST: [CONSULTING SPECIALIST'S NAME]
DATE/TIME OF CONSULT: [DATE AND TIME OF CONSULTATION]
REASON FOR CONSULT: [BRIEF DESCRIPTION OF REASON FOR CONSULTATION]
CURRENT CONDITION: [BRIEF SUMMARY OF PATIENT'S CURRENT MENTAL HEALTH CONDITION]

MENTAL HEALTH HISTORY: [SUMMARY OF PATIENT'S MENTAL HEALTH HISTORY]
MEDICATION HISTORY: [LIST OF CURRENT AND PAST MEDICATIONS WITH DOSAGES]
PSYCHOSOCIAL HISTORY: [SUMMARY OF RELEVANT PSYCHOSOCIAL FACTORS]
SUBSTANCE USE HISTORY: [SUMMARY OF PATIENT'S SUBSTANCE USE HISTORY]
FAMILY HISTORY: [OVERVIEW OF FAMILY MENTAL HEALTH HISTORY]

REFERRING CLINICIAN'S OBSERVATIONS: [OBSERVATIONS AND CONCERNS FROM REFERRING CLINICIAN]
CONSULTING SPECIALIST'S ASSESSMENT: [ASSESSMENT FINDINGS BY CONSULTING SPECIALIST]
CURRENT SYMPTOMS: [LIST OF CURRENT MENTAL HEALTH SYMPTOMS OBSERVED]
SUICIDE/HOMICIDE RISK ASSESSMENT: [SUMMARY OF SUICIDE/HOMICIDE RISK ASSESSMENT]
MENTAL STATUS EXAM FINDINGS: [SUMMARY OF MENTAL STATUS EXAMINATION FINDINGS]

TREATMENT RECOMMENDATIONS: [RECOMMENDATIONS FOR TREATMENT INTERVENTIONS]
MEDICATION MANAGEMENT: [PROPOSED MEDICATION MANAGEMENT PLAN]
THERAPY/COUNSELING: [RECOMMENDATIONS FOR THERAPY OR COUNSELING]
COLLABORATIVE CARE PLAN: [PLAN FOR COLLABORATION WITH OTHER HEALTHCARE PROVIDERS]
FOLLOW-UP INSTRUCTIONS: [INSTRUCTIONS FOR FOLLOW-UP CARE AND MONITORING]

QUESTIONS FOR CONSULTING SPECIALIST:

- [ANY QUESTIONS FOR THE CONSULTING SPECIALIST]

CONCERNS TO ADDRESS:

- [SPECIFIC CONCERNS TO ADDRESS DURING CONSULTATION]

NEXT STEPS:

- [PLAN FOR NEXT STEPS IN PATIENT MANAGEMENT]