Psychiatry — Child/Adolescent Psychiatric Intake Template
The Child/Adolescent Psychiatric Intake Template is designed for child and adolescent psychiatrists and psychiatric nurse practitioners conducting initial evaluations for patients under age 18. This comprehensive template documents developmental history, family history, school performance, psychiatric symptoms, mental status examination, risk assessment, and treatment planning. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint and reason for referral, developmental history including milestones and delays, school performance and behavioral concerns, family psychiatric and medical history, social history including peer relationships and activities, psychiatric symptoms appropriate for age, collateral information from parents, teachers, or other sources, mental status examination adapted for age, suicide and self-harm risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including family involvement, and follow-up scheduling. This template ensures thorough child/adolescent psychiatric evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and establishes foundation for ongoing psychiatric care. Ideal for child and adolescent psychiatry practices, pediatric mental health clinics, and practices managing psychiatric care for minors.
Template
Visit Information
Patient name, DOB, age: [X] years
Referral source: [If applicable]
Present: [Patient, parents, both]
Chief Complaint
[Patient's and/or parent's stated reason for evaluation]
Developmental History
Pregnancy/birth: [Complications if any]
Milestones: [Motor, language, social]
Delays: [If any]
School: [Performance, behavior, special services]
Presenting Concerns
Symptoms: [Depression, anxiety, ADHD, behavior, etc.]
Onset: [When symptoms began]
Duration: [How long present]
Impact: [School, family, peers]
School Performance
Academic: [Grades, performance]
Behavior: [Behavior at school]
Social: [Peer relationships]
Special services: [IEP, 504, etc.]
Family History
Psychiatric: [Family mental illness]
Medical: [Relevant family history]
Family functioning: [Family dynamics, stressors]
Social History
Peer relationships: [Friends, social activities]
Activities: [Extracurricular, interests]
Trauma: [If applicable]
Collateral Information
From parents: [Key information]
From school: [If available]
From other providers: [If applicable]
Mental Status Examination
Appearance: [Grooming, dress]
Behavior: [Cooperation, activity level]
Speech: [Rate, volume]
Mood: [Subjective and observed]
Affect: [Range, reactivity]
Thought: [Process, content]
Cognition: [Age-appropriate]
Insight/Judgment: [Age-appropriate]
Risk Assessment
Suicide risk: Low / Moderate / High
Self-harm: [If present]
Safety: [Assessment]
Assessment
1) [Primary diagnosis] — [ICD-10 code]
- Severity: Mild / Moderate / Severe
2) [Other diagnoses as applicable]
Plan
1) Treatment: [Medication, therapy, family therapy]
2) School: [Accommodations if needed]
3) Family: [Family involvement]
4) Safety: [If indicated]
5) Follow-up: [Next appointment]
Parent/Patient Education
Diagnosis explained. Treatment options discussed. Family verbalized understanding.
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