Psychiatric assessment (1st appointment)

Patient Name: [Full name] Date of Assessment: [e.g. 9 July 2025] NHS/Clinic Number: [If applicable] Seen by: [Clinician's name, role] Setting: [In-person / Video consultation / Phone] Duration: [e.g. 60 minutes] 1. Reason for Assessment / Referral [Briefly outline the referral source, purpose of the assessment, and key presenting concerns. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 2. History of Presenting Problems Symptom Onset: [When the difficulties began, precipitating events. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Course and Duration: [Intermittent, chronic, worsening, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Current Symptoms: [Mood, sleep, energy, anxiety, irritability, attention, motivation, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Impact on Functioning: [Work, relationships, parenting, self-care, social life. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Coping and Insight: [How the person understands their difficulties; any self-help or coping strategies. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Goals and Expectations: [What the patient hopes to gain from the assessment/treatment. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 3. Past Psychiatric History Previous Diagnoses: [Include when, where, and by whom if known. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Psychological Therapies: [Type, duration, outcome. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Medication History: [Current and previous, including response and side effects. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Hospital Admissions / Crisis Support: [Dates, reasons, outcomes. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] History of Self-harm or Suicidal Thoughts: [Past and present; include context and risk if applicable. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 4. Medical History Physical Health Problems: [Past or current. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Medications: [Prescribed and over-the-counter. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Allergies: [Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.] Relevant Screening / Investigations: [If applicable, e.g. thyroid, B12, MRI. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 5. Family History Psychiatric Conditions in Family: [Especially mood disorders, neurodevelopmental conditions, suicide. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Family Dynamics: [Parenting style, attachment, trauma if relevant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 6. Personal History Birth and Early Development: [Include delays or complications if relevant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Childhood Environment: [Parenting, safety, emotional climate. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Schooling and Peer Relationships: [Any bullying, learning difficulties, friendships. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Adolescence: [Mood, identity development, relationships. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Trauma History: [If relevant, include emotional, physical, sexual abuse, neglect. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Occupational History: [Qualifications, work pattern, current role. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Relationship History and Sexuality: [Partnerships, break-ups, orientation if relevant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Children / Parenting Role: [Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.] Substance Use: [Alcohol, recreational or prescription drugs, caffeine, nicotine. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Forensic History: [Any past involvement with the police or legal system. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 7. Mental State Examination (As observed at the time of assessment) Appearance and Behaviour: [Grooming, posture, eye contact, psychomotor activity. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Speech: [Rate, volume, coherence. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Mood and Affect: [Subjective mood, congruence, range. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Thought Form and Content: [Coherence, rumination, worry, intrusive thoughts, delusions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Perception: [Hallucinations, dissociation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Cognition: [Orientation, memory, attention – brief comment. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Insight and Judgement: [Understanding of illness, help-seeking behaviour. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 8. Risk Assessment To Self: [Self-harm, suicidal thoughts or behaviours – current and historical. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] To Others: [Aggression, irritability, violent thoughts or behaviours. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] From Others: [Vulnerability, domestic abuse, coercion or exploitation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Safeguarding Concerns: [If relevant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Protective Factors: [Supportive relationships, coping skills, insight. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 9. Formulation A biopsychosocial summary bringing together the key aspects of the case: Predisposing Factors: [e.g. family history, early experiences, personality. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Precipitating Factors: [Recent stressors, losses, transitions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Perpetuating Factors: [Current environment, habits, cognitive styles, relationships. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Protective Factors: [Motivation, supports, insight, strengths. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 10. Diagnosis / Provisional Diagnosis [Use ICD-10 or DSM-5 format where appropriate. If no diagnosis is reached, note this and explain why. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 11. Plan and Recommendations [Any investigations, e.g. blood tests, imaging. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Medication advice – consider shared decision-making. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Psychological therapy recommendations. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Signposting to services or self-help resources. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [Next steps – follow-up plans or referrals. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] 12. Capacity and Consent [The patient] has the capacity to consent to assessment and treatment. Consent was obtained. I have no concerns regarding risk at this stage. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)