Initial Assessment
Created by
Jennifer Miller
Specialty
Nurse Practitioner
Last edited
10/20/2026
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0 times
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About this template
A structured template for Nurse Practitioners completing comprehensive initial psychiatric evaluations. It covers presenting concerns, DSM-V symptom domains, psychiatric and medical history, family and social context, substance use, risk, diagnosis, and treatment planning.
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History of Presenting Complaints
34 yo F presents on 15/10/2023 at 14:30 for evaluation of worsening low mood and excessive worry over the past 3 months, precipitated by a job layoff. Reports persistent sadness, anhedonia, middle insomnia (waking 3-4 times/night), and daily fatigue. Also notes constant, uncontrollable worry regarding finances, accompanied by restlessness, muscle tension, and poor concentration, impairing ability to seek new employment. Denies panic attacks, manic episodes, or perceptual disturbances.
Psychiatric Review of Systems
- Depression: Depressed mood, anhedonia, insomnia, fatigue, diminished concentration
- Mania: Client did not endorse
- Anxiety: Excessive worry, restlessness, easily fatigued, difficulty concentrating, muscle tension, sleep disturbance
- Psychosis: Client did not endorse
- Trauma: Client did not endorse
- Eating Disorder: Client did not endorse
- ADHD: Client did not endorse
- Autism Spectrum: Client did not endorse
- ODD / Conduct / Antisocial: Client did not endorse
- Personality Disorder: Client did not endorse
Past Psychiatric History
- Adjustment disorder with depressed mood (2018), treated with brief CBT.
- 0 psychiatric hospitalizations.
- Currently taking no psychotropic medications.
- Previously trialed escitalopram (Lexapro®) 10 mg PO daily in 2018 for 6 months (stopped due to resolution of symptoms; well tolerated).
Past Medical History
- Primary hypertension, well-controlled on lisinopril (Prinivil®) 10 mg PO daily.
- Laparoscopic appendectomy (12/05/2015).
Family History
- Mother: Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD).
- Paternal uncle: Alcohol Use Disorder.
Substance use History
- Tobacco: Never smoker.
- Alcohol: 1-2 standard drinks (wine) 2x/week; last use 12/10/2023.
- Recreational drugs: Denies any history of illicit drug or cannabis use.
Social History
- Born and raised in Austin, TX; currently resides in a rented apartment in Chicago, IL with husband and 4 yo daughter.
- Unemployed marketing manager (laid off 07/2023); holds a Bachelor of Business Administration.
- Supportive marriage; close relationship with mother and two local friends.
- No current legal issues.
Risk Assessment
- Denies active or passive suicidal ideation, intent, or plan; no history of self-harm or suicide attempts. Denies homicidal ideation. Low acute risk of harm to self or others.
Diagnosis
Major Depressive Disorder, single episode, moderate (F32.1) and Generalized Anxiety Disorder (F41.1) per DSM-5 criteria. PHQ-9: 15 (moderately severe depression); GAD-7: 14 (moderate anxiety).
Treatment Plan
- Order CBC, CMP, TSH, and vitamin D levels to rule out organic contributors.
- Start sertraline (Zoloft®) 25 mg PO daily for 7 days, then increase to 50 mg PO daily.
- Discussed sleep hygiene and behavioral activation strategies; provided psychoeducation regarding SSRI onset and side effects.
- Referral placed for outpatient CBT; RTC in 4 weeks (12/11/2023 at 10:00) to assess medication tolerance and efficacy.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.