Psych Evaluation
Psych Evaluation
[YOUR COMPANY NAME]
Patient Information:
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Name:
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Date of Birth:
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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:
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1 = Poor
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2 = Below Average
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3 = Average
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4 = Above Average
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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]
