A psychiatric intake evaluation is the comprehensive first assessment a psychiatrist or psychiatric NP completes with a new patient, covering the presenting problem, psychiatric and medical history, a mental status exam, a structured risk assessment, and an initial diagnosis and treatment plan. It's the single most important note in the chart: every progress note, prior authorization, and audit that follows is measured against what you document here.

Below you'll find a free, downloadable psychiatric intake evaluation template, a breakdown of every section it should include, a step-by-step guide to writing an intake that establishes medical necessity from visit one, and the mistakes that most often weaken these notes in review.

Quick download: Grab the free Psychiatric Intake Evaluation template PDF here.

Key Takeaways

• The intake is your audit anchor: The diagnosis, functional impairment, and measurable treatment goals you record at intake are what every later note is judged against. If medical necessity isn't established here, it's hard to establish anywhere.
  
  

• "Denies SI/HI" is not a risk assessment: A defensible intake documents dynamic, static, and protective factors, access to means, and a safety plan, not a single negative line.
  
  

• The mental status exam is observation, not history: Keep what the patient tells you in the HPI and what you observe in the MSE. Mixing the two is one of the most common documentation errors in psychiatry.
  
  

• Baseline measures make progress provable: Recording rating scale scores (PHQ-9, GAD-7) and vitals at intake gives every future visit an objective comparison point, and gives payers the measurement-based care they increasingly expect. An AI medical scribe can draft the full intake note in your template while you focus on the patient.
  
  

What Is a Psychiatric Intake Evaluation?

A psychiatric intake evaluation (also called an initial psychiatric evaluation or psychiatric diagnostic evaluation) is the structured first encounter between a psychiatric clinician and a new patient. It typically runs 60–90 minutes and produces the foundational document of the treatment relationship: the note that establishes the diagnosis, the severity and functional impact of the illness, the initial risk formulation, and the treatment plan.

In billing terms, this is the visit coded as 90791 (psychiatric diagnostic evaluation) or 90792 (psychiatric diagnostic evaluation with medical services, used by prescribers). Both codes carry a documentation expectation that goes well beyond a standard office visit, which is exactly why a prompted template matters.

Think of the intake as the load-bearing wall of the chart. A progress note can be brief because it leans on the intake. If the intake is thin, everything built on top of it is thin too.

What to Include in a Psychiatric Intake Evaluation

There's no single mandated format, but strong intake notes converge on the same core sections. Our free template covers all of them across three pages:

• Identifying information & chief complaint: Demographics, referral source, and the presenting problem, ideally in the patient's own words.
  
  

• History of present illness (HPI): Onset, duration, course, severity, triggers, prior episodes, and, critically, functional impairment at work, school, home, and in relationships. If you want a deeper structure for this section alone, see our HPI template.
  
  

• Past psychiatric history: Prior diagnoses, hospitalizations, suicide attempts and self-harm, past medication trials with doses and outcomes, and previous therapy.
  
  

• Medical history & current medications: Relevant medical conditions, allergies, and a full medication list, including anything that could interact with psychotropics.
  
  

• Substance use history: Substances, amounts, frequency, last use, prior treatment, and periods of sobriety. Screen everyone, not just patients who "look like" they use.
  
  

• Family & social history: Psychiatric illness and suicide in first-degree relatives, plus living situation, relationships, employment, legal history, and trauma history. For a fuller framework here, our biopsychosocial assessment template pairs well with the intake.
  
  

• Psychiatric review of systems: A structured sweep for mood, anxiety, psychosis, OCD, PTSD, eating, and attention symptoms the patient didn't volunteer.
  
  

• Mental status exam (MSE): Appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight, and judgment: what you observe in the room, at this visit.
  
  

• Risk assessment: Structured documentation of suicide and violence risk: dynamic factors, static factors, protective factors, access to means, and the safety plan you made together.
  
  

• Assessment, diagnosis & plan with baseline measures: DSM-5-TR diagnoses with the supporting criteria, measurable treatment goals, medication and therapy plan, labs, and baseline rating scale scores and vitals for future monitoring.
  
  

Pro tip: Write your treatment goals so a stranger could verify them at the next visit. "Reduce PHQ-9 from 18 to below 10 within 12 weeks" survives an audit. "Improve mood" doesn't.

Psychiatric Intake Example: Risk Assessment & MSE

The two sections clinicians most often under-document are the MSE and the risk assessment, so here's what "done well" looks like in a condensed, fictitious example.

Mental Status Exam: 34-year-old female, appears stated age, casually dressed, adequate grooming. Cooperative, intermittent eye contact. Speech normal rate and volume. Mood "exhausted"; affect constricted, congruent. Thought process linear and goal-directed. No delusions or perceptual disturbances. Passive death wish endorsed (see risk assessment); no intent or plan. Alert and oriented x4; attention and memory grossly intact. Insight fair; judgment fair.

Risk Assessment: Endorses passive suicidal ideation ("sometimes I wish I wouldn't wake up") 2–3x/week over the past month; denies active ideation, intent, plan, or preparatory behavior. Columbia Protocol administered; screens positive for ideation, negative for behavior. Dynamic factors: worsening insomnia, recent job loss, alcohol use 3–4 drinks nightly. Static factors: prior attempt at age 19, family history of completed suicide (paternal uncle). Protective factors: engaged with two young children, strong therapeutic alliance with outpatient therapist, future-oriented. Means: no firearms in home; medications stored by spouse per plan. Safety plan completed and copy given to patient; patient verbalized warning signs and crisis contacts. Overall acute risk: low-to-moderate, appropriate for outpatient management with 1-week follow-up.

Notice what makes this defensible: specifics, a named screening tool, factors sorted into categories, and a documented plan, not a checkbox.

How to Write a Strong Psychiatric Intake: Step by Step

A template gives you the structure. These five habits turn it into a note that holds up clinically and in review.

1. Anchor the HPI to function

Symptoms alone don't establish medical necessity; impairment does. For every major symptom cluster, document how it affects work, school, relationships, sleep, and self-care. "Depressed mood daily for 6 weeks, missing 2–3 workdays per week, stopped attending daughter's activities" builds a case that "reports depression" never will.

2. Structure the risk assessment

Use a validated framework like the Columbia Protocol (C-SSRS) and document dynamic, static, and protective factors separately, along with access to means and the safety plan. This is the section most scrutinized after an adverse event, and the section most often reduced to a single line. Don't let it be.

3. Keep the MSE strictly observational

The MSE describes this patient, in this room, at this visit. "Patient reports hearing voices last week" belongs in the HPI; "no response to internal stimuli observed" belongs in the MSE. Separating the two shows diagnostic rigor and makes the note far easier to defend.

4. Record every prior medication trial with the outcome

"Tried Zoloft, didn't work" is a wasted line. "Sertraline 100 mg x 10 weeks in 2023, partial response, discontinued for GI side effects" prevents repeating failed trials, supports future prior authorizations, and is often the difference in getting a second-line agent approved.

5. Capture baseline measures before treatment starts

Administer and record scores for at least one validated scale (PHQ-9 for depression, GAD-7 for anxiety), plus vitals and any labs you're ordering. Measurement-based care starts at intake; without a baseline, "patient improving" is just an opinion.

Bottom line: Specific, structured, and functional beats long. A tight three-page intake with a real risk formulation and measurable goals outperforms a six-page narrative every time.

Common Psychiatric Intake Mistakes to Avoid

• "Denies SI/HI" as the entire risk assessment. Replace it with a structured formulation: factors, means, safety plan, and your risk conclusion.
  
  

• Mixing reported history into the MSE. Keep observations and history in their own sections.
  
  

• Diagnosis without criteria. Listing "MDD, moderate" without the supporting DSM-5-TR symptoms invites a downgrade in audit. Tie the diagnosis to documented findings.
  
  

• Vague treatment goals. "Stabilize mood" isn't measurable. Anchor goals to scale scores, frequencies, or functional milestones.
  
  

• Skipping substance use screening. Undocumented substance use is one of the most common confounders of a failed treatment plan, and one of the easiest to prevent at intake.
  
  

Psychiatric Intake vs. Progress Note vs. Biopsychosocial Assessment

These three documents get conflated constantly. Here's how they differ:

The intake is the anchor; the other two either build on it or complement it.

Faster Psychiatric Intakes with Sully.ai

A 60-90 minute intake often generates another 30–45 minutes of after-hours documentation, and the intake is the note you can least afford to rush. That's the gap an AI medical scribe closes.

With Sully.ai, you start the scribe at the beginning of the encounter and stay fully present with the patient, which matters more in psychiatry than in almost any other specialty. By the end of the visit, a structured intake note is drafted in your exact template: HPI with functional impairment, complete MSE, structured risk assessment, and a plan with baseline measures, ready for your review and sign-off.

For practices, the benefits compound:

• Intakes stop bleeding into evenings, because real-time note generation happens during the visit, not after it.
  
  

• Notes are more complete and more billable, since prompted sections like medication trial history and risk factors get captured live rather than reconstructed, which pays off downstream in billing and coding.
  
  

• Clinicians can actually look at the patient, instead of typing through the most rapport-sensitive visit in medicine.
  
  

Sully.ai is built for healthcare from the ground up and meets HIPAA standards for handling protected health information.

Frequently Asked Questions

What is included in a psychiatric intake evaluation?

A complete psychiatric intake includes the chief complaint, history of present illness with functional impairment, past psychiatric and medical history, current medications and prior medication trials, substance use history, family and social history, a psychiatric review of systems, a mental status exam, a structured risk assessment, and an assessment and plan with DSM-5-TR diagnoses, measurable goals, and baseline measures.

How long does a psychiatric intake evaluation take?

Typically 60–90 minutes for the encounter itself, plus documentation time. Complex presentations (multiple diagnoses, extensive medication history, active risk) run longer. The documentation burden is why many practices now pair a structured template with an AI scribe.

What is the difference between CPT codes 90791 and 90792?

90791 is a psychiatric diagnostic evaluation without medical services, typically used by psychologists and therapists. 90792 includes medical services (prescribing, physical exam elements, medical decision-making) and is used by psychiatrists and psychiatric NPs. Both cover the initial evaluation; neither is time-based like standard E/M codes.

How do you document suicide risk in a psychiatric intake?

Use a structured approach: administer a validated screener like the C-SSRS, then document dynamic risk factors, static risk factors, protective factors, and access to lethal means separately. Close with your overall risk formulation, the level of care it supports, and the safety plan completed with the patient. Avoid single-line documentation like "denies SI/HI."

Is a psychiatric intake the same as a biopsychosocial assessment?

No. They overlap, but the psychiatric intake is a medical diagnostic evaluation producing DSM-5-TR diagnoses, a risk formulation, and a medication-inclusive treatment plan. A biopsychosocial assessment is a broader formulation of contributing factors, often completed by therapists or social workers at the start of therapy. Many patients will have both in their chart.

Can I customize this psychiatric intake template?

Yes. Start from the free template, then adapt the prompts to your specialty, patient population, state requirements, and payer expectations. Once your structure is set, an AI scribe can generate every intake note in that exact format automatically.

This template is provided for documentation reference only. Adapt it to your specialty, state requirements, and payer expectations. It does not replace clinical judgment.

This article is for general informational purposes and is not legal or medical advice. Confirm that any form you use meets applicable regulations, including HIPAA, and consult your compliance team before deploying it.