What CPT codes are used for psychiatric intake evaluations?

Initial psychiatric evaluation uses 90791 (diagnostic evaluation without medical services) or 90792 (with medical services including physical exam or medication management). Most comprehensive intakes with medication evaluation use 90792. For extended evaluations, document time spent. E/M codes can be used instead if primarily addressing medical conditions with psychiatric components.

What mental status examination documentation is required?

Document: appearance (grooming, dress, hygiene), behavior (psychomotor activity, eye contact, cooperation), speech (rate, tone, volume, latency), mood (patient's subjective description), affect (observed range, congruence, appropriateness), thought process (linear, tangential, circumstantial), thought content (SI, HI, delusions, obsessions), perception (hallucinations), cognition (orientation, memory, concentration), insight, and judgment.

How should suicide risk assessment be documented?

Document: direct assessment of suicidal ideation (asked directly, not inferred), presence/absence of plan, intent, means access, protective factors (reasons for living, religious beliefs, family, future orientation), past attempts with lethality, current mental state, and risk level determination (low/moderate/high). Document safety plan or hospitalization decision if indicated. Never omit even when negative.

What substance use history documentation is needed?

Document: each substance used (alcohol, cannabis, opioids, stimulants, benzodiazepines, etc.), age of first use, pattern of use (frequency, amount), last use, withdrawal history, prior treatment, and current use status. Include impact on functioning and co-occurring psychiatric symptoms. Use CAGE, AUDIT, or DAST if appropriate. Substance use affects diagnosis and treatment selection.

What treatment history documentation supports diagnosis?

Document: prior psychiatric diagnoses with dates and sources, previous hospitalizations with reasons and outcomes, prior medication trials (drug, dose, duration, response, reason stopped), prior therapy (type, duration, benefit), and ECT or other treatments. Treatment response history informs current diagnosis and treatment selection. Include records reviewed.

Adult Psychiatric Intake Template - New Patient Evaluation

Psychiatry — Adult Psychiatric Intake Template

Psychiatry Psychiatry Updated: 11/7/2025

The Adult Psychiatric Intake Template is designed for psychiatrists and psychiatric nurse practitioners conducting initial evaluations for adult patients (ages 18+). This comprehensive template documents psychiatric history, mental status examination, risk assessment, diagnostic formulation, and initial treatment planning. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint and reason for referral, history of present illness with detailed symptom assessment, past psychiatric history including diagnoses and treatments, substance use history, medical history and medications, family psychiatric history, social and developmental history, complete mental status examination, suicide and violence risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including medication and therapy recommendations, safety planning if indicated, and follow-up scheduling. This template ensures thorough psychiatric evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and establishes foundation for ongoing psychiatric care. Ideal for outpatient psychiatry clinics, private practice psychiatrists, community mental health centers, and integrated behavioral health programs.

Visit Information

Patient name, DOB, age, gender
Date of evaluation
Referral source: [If applicable]
Insurance: [If relevant]

Chief Complaint

[Patient's stated reason for evaluation]

History of Present Illness

Onset: [When symptoms began]
Duration: [How long symptoms present]
Precipitating factors: [Stressors, life events]
Course: [Progression of symptoms]
Severity: [Impact on function]
Previous episodes: [If applicable]
Previous treatments: [What has been tried]

Psychiatric Symptoms

Mood: [Depressed, anxious, irritable, etc.]
Anxiety: [Worry, panic, avoidance]
Psychotic: [Hallucinations, delusions if present]
Other: [Sleep, appetite, energy, concentration, etc.]

Past Psychiatric History

Previous diagnoses: [List with dates]
Previous hospitalizations: [If applicable]
Previous medications: [List with response]
Previous therapy: [Type and duration]
Suicide attempts: [If applicable]

Substance Use

Alcohol: [Quantity, frequency]
Cannabis: [If applicable]
Other substances: [If applicable]
Tobacco: [If applicable]

Medical History

Current medical conditions: [List]
Current medications: [List with dosages]
Allergies: [List]

Family Psychiatric History

[Family history of mental illness, substance use]

Social History

Employment: [Status]
Relationships: [Marital, family]
Living situation: [Housing, support]
Legal: [If relevant]

Mental Status Examination

Appearance: [Grooming, dress]
Behavior: [Cooperation, eye contact]
Speech: [Rate, volume, tone]
Mood: [Subjective]
Affect: [Observed]
Thought process: [Organization]
Thought content: [SI, HI, delusions]
Perception: [Hallucinations]
Cognition: [Orientation, memory]
Insight: [Awareness of illness]
Judgment: [Decision-making]

Risk Assessment

Suicide risk: Low / Moderate / High
[Details if risk present]
Violence risk: Low / Moderate / High
[Details if risk present]

Assessment

1) [Primary psychiatric diagnosis] — [ICD-10 code]

Severity: Mild / Moderate / Severe

2) [Other diagnoses as applicable]

Plan

1) Medication: [Recommendations with rationale]
2) Therapy: [Recommendations]
3) Safety planning: [If indicated]
4) Labs: [If indicated]
5) Follow-up: [Next appointment]

Patient Education

Diagnosis explained. Treatment options discussed. Patient verbalized understanding.