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Header Information
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Telepsychiatry
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Date of initial consult or first appt with you :
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Subjective hx:
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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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Psychosis
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Specify psychotic symptoms
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Medication Side Effects:
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If Medication Side Effects, explain:
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Pt Denies Alcohol/Illicit Drug Use:
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If no, please specify substance, frequency, amount:
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Assessment
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Assessment Content:
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Treatment Plan:
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Treatment Plan:
• • •
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Schedule follow up?
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Follow Up Content:
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Refer to outside provider?
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Referred to:
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Additional Recommendations?
• • •
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Additional Recommendations (free text):
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Risks/Benefits Statement
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