Psychiatric Intake Evaluation Template

The Psychiatric Intake Evaluation template covers the full initial assessment across three pages: history and present illness, past psychiatric and medical history, medications, substance use, family and social history, a psychiatric review of systems, a complete mental status exam, a structured risk assessment covering dynamic, static, and protective factors plus means access and safety planning, and a baseline measures section for rating scales, vitals, and monitoring.

This is the note that carries the most weight in an audit, because the diagnosis, the functional impairment, and the measurable goals recorded here are what every later progress note is measured against. The template prompts for each of those explicitly, so the course of treatment starts on defensible ground. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.