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Header Information
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CPT
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Telepsychiatry
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Identifying Data:
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Chief Complaint/Presenting Problem:
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EVALUATE PATIENT FOR TMS AND CBH
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History of Present Illness:
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Client Quote:
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HPI Free Box
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Anxiety
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Depression
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Bipolar
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PTSD
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ADHD
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OCD
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Borderline Personality
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Narcissitic Personality
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Current Medications:
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Medication Side Effects:
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If Medication Side Effects, explain:
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PHQ-9
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PHQ-9 Score
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GAD-7
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GAD-7 Score
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PCL-5
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PCL-5 Score
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Y-BOCS
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Y-BOCS Score
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WHO-5
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WHO-5 Score
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Past Psychiatric History:
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H/O Inpatient/ Residential Treatment:
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If H/O Inpatient/ Residential Treatment, explain:
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H/O PHP/IOP:
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If H/O PHP/IOP, explain:
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H/O Suicide Attempts:
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If H/O Suicide Attempts, explain:
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H/O Mania:
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If H/O Mania, explain:
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Additional Past Psychiatric History:
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If H/O Psych Dx/Therapy/Meds/Other, explain:
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Social History:
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Born/Raised:
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Highest Level of Education:
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Marital Status/ Children:
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Currently living:
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Employment:
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Abuse/ Trauma:
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Access to Firearms:
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If access to firearms, explain:
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Family History:
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Additional Family History:
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Family/ Social Support:
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Habits:
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Nicotine Products:
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If Pt uses tobacco, explain:
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Alcohol:
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If Pt uses alcohol, explain:
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THC:
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If Pt uses marijuana, explain:
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Illicit Drugs:
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If Pt uses Illicit drugs, explain:
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IVDA:
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If IVDA, explain:
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MSE:
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Appearance:
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A & O:
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Behavior:
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Speech:
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Affect:
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TP:
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Cognition:
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Insight
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Judgement
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Mood
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Mood:
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SI:
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SI
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Contracts for Safety
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HI
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HI
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Suicide Risk Assessment
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Suicide Risk Factors
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Protective Factors:
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Additional info:
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Diagnostic Impression:
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DI: Major Depressive Disorder
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DI: Bipolar
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DI: Anxiety Disorders:
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DI- Substance Use Disorders:
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DI: ADHD
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DI: Eating Disorders
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DI: Personality Disorders
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DI: Cognition
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DI: Other Disorders
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DI: Other Disorders (not listed):
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Problem List
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Other Problems (not listed):
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Treatment Plan:
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Assessement:
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Outpatient Care Appropriate
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If outpatient care is NOT appropriate, recommended:
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TMS Discussed?
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If TMS was discussed, explain:
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Clear Behavioral Center Discussed?
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If CBH was discussed, explain:
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Client referred to CCC to/for:
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ROI signed for
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Planned Therapeutic Intervention
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Targeted Goals:
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Homework Assignments:
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Additional treatment plans:
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Follow Up:
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Client not accepted as a new patient
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If not accepted, explain reason and referral.
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Psychotherapy Start Time:
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End Time (MUST BE 53-60 MINUTES):
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Therapist supervisor:
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Risks/Benefits Statement
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Client Rights
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