Initial Evaluation Template:

Initial Evaluation Template: Identification: John Doe, 45, Male Chief Complaint: "I have been feeling extremely anxious and unable to sleep for the past few weeks." History of Present Illness: John Doe reports a gradual onset of anxiety symptoms over the past month, with increasing severity. He describes difficulty sleeping, feeling restless, and experiencing frequent worry about work and personal life. Psychiatric review of systems: Depressive symptoms: Reports feeling down and lacking energy. Anxiety symptoms: Experiences excessive worry and restlessness. Sleep: Reports difficulty falling and staying asleep. Appetite: Decreased appetite noted. Suicidal and homicidal ideations: Denies any suicidal or homicidal thoughts. Auditory and visual hallucinations: Denies any hallucinations. Delusions/paranoia: No delusional or paranoid thoughts reported. Manic symptoms: Denies any manic symptoms. Past Psychiatric History: - Prior diagnosis: Generalized Anxiety Disorder - Hospitalizations in psychiatric units: None - Previous suicide attempts: None - History of self harm: None - Access to firearms: No access - Psychotropic medications: Previously prescribed Sertraline - Current psychiatrist and therapist: Dr. Emily Smith, Therapist: Jane Doe - Cures report: Available Family History of psychiatric/substance use history: Mother with history of depression Substance Use History: - Alcohol: Occasional use, 1-2 drinks per week - Cannabis: None - Amphetamines: None - Nicotine: Smokes 5 cigarettes per day - Other substances: None Medical History: Hypertension, managed with medication Medical Review of systems: No significant findings Current Medications: Lisinopril 10mg daily Allergies: Penicillin Social History: - Marital Status: Married - Children: Two children, ages 10 and 12 - Living situation: Lives with spouse and children - Employment: Works as an accountant - Education: Bachelor's degree in Accounting - Support System: Strong family support Objective: Mental Status Evaluation: Appearance: Well-groomed, casually dressed Cognition: Alert and oriented Speech: Normal rate and volume Mood: Anxious Affect: Congruent with mood TP: Logical and coherent TC: No suicidal or homicidal ideations, no delusions Perc: No perceptual disturbances Insight/Judgment: Good insight and judgment Assessment: John Doe presents with symptoms consistent with Generalized Anxiety Disorder, exacerbated by recent stressors. Plan: 1. Risk Assessment: Low risk for self-harm, protective factors include family support 2. Status: Voluntary 3. Diagnostics: None indicated at this time 4. Treatment: 5. Bio: Restart Sertraline 50mg daily, discuss potential side effects 6. Psychosocial: Cognitive Behavioral Therapy, safety planning, referral to support group 7. Patient's Participation in treatment plan: Patient is willing to engage in therapy and medication management Therapeutic Interventions: Cognitive Behavioral Therapy, 60-minute session Symptoms or Challenges Discussed: Anxiety management, sleep hygiene Impact on the Patient's Functioning: Anxiety impacting work performance and family interactions Specific Topics Covered: Coping strategies, relaxation techniques Client's Response: Patient engaged and receptive to interventions Prognosis: Good, with adherence to treatment plan Diagnosis: Generalized Anxiety Disorder (F41.1) Billing Codes: 99205, 90834 Provider's name: Dr. Thomas Kelly