Session Info

CPT code (90792):

Session duration (min):

Modality:

In-person

Telehealth

Attendance:

Client

Parent / Guardian

Collateral

Interpreter

Consent:

Informed consent reviewed and signed

Telehealth consent (if applicable)

Releases of information signed

Chief Concern & HPI

Chief concern:

History of present illness:

Functional impairment:

Occupational / Academic

Social / Relational

Self-care / ADLs

Daily functioning

Psychiatric History

Prior diagnoses:

Hospitalizations / Higher LOC:

Prior medication trials:

Psychotherapy history:

Medical & Family History

Medical history:

Family psychiatric history:

Allergies:

Reproductive / Pregnancy considerations:

Substance Use

Alcohol:

Cannabis:

Other substances:

Treatment history / Withdrawal risk:

Social History

Living situation:

Work / School:

Supports:

Legal / Trauma considerations:

Examination

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

ROS Quick Screen

Constitutional — WNL (no fever, weight change, fatigue)

Sleep disturbance

Appetite / Weight change

Energy change

Sexual dysfunction

GI complaint

Cardiopulmonary symptom

Endocrine concern

ROS notes:

Mental Status Exam

Appearance:

Well-groomed

Disheveled

Age-appropriate dress

Behavior:

Cooperative

Guarded

Agitated / Restless

Good eye contact

Speech:

Normal rate and volume

Pressured / Rapid

Slow / Soft

Mood / Affect:

Euthymic

Depressed

Anxious

Irritable

Euphoric / Elevated

Affect congruent / full range

Affect flat / restricted / blunted

Labile

Thought Process:

Linear and goal-directed

Circumstantial

Tangential

Loose associations

Flight of ideas

Thought Content:

No SI / No HI

SI present — see C-SSRS below

HI present — see risk documentation

Delusions (paranoid / grandiose / somatic)

No perceptual disturbances (AH / VH)

Cognition:

Alert and oriented ×4

Memory intact

Cognitive screen (MoCA / MMSE) — score:

Insight / Judgment:

Insight: Good / Fair / Limited / Poor

Judgment: Good / Fair / Poor

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Safety disposition, protective factors, and follow-up actions documented

Counseling - Initial Psychiatric Evaluation

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