Psychiatry templates
Free Psychiatry document templates written and shared by clinicians on Rhazes. Preview any template, then save it to your own library.
49 shared by clinicians · Page 1 of 2
- Comprehensive Adult ADHD Evaluation TemplateThis template supports comprehensive initial ADHD assessments for adults. It covers identifying information, mental state examination, developmental and psychosocial history, ADHD symptoms, functional impairment, and diagnostic impressions.
Psychiatry
- Psychiatric Assessment ReportA structured template for documenting a comprehensive psychiatric evaluation, including diagnoses, medications, investigations, background, mental state, risk, formulation, treatment, and safety planning. It is designed to support thorough clinical records using only explicitly provided information.
Psychiatry
- ADHD Review TemplateA structured template for documenting follow-up reviews of ADHD treatment. It covers medication use and response, current symptoms, adverse effects, physical monitoring, investigations, risk, mental state examination, and the treatment plan.
Psychiatry
- ADHD Diagnostic Outcome And Medication Plan LetterA reusable letter framework for communicating the outcome of an ADHD assessment and the start of medication to primary care and the patient. It covers diagnostic findings, presentation, relevant history, treatment choices, prescribing, monitoring, safety advice, follow-up, and crisis information.
Psychiatry
- Play Therapy NoteThis template structures documentation of therapeutic play sessions with children. It captures the session presentation, play activities and symbolic themes, treatment response, progress, goals, and follow-up planning.
Psychiatry
- Psychiatric Assessment LetterA structured template for documenting comprehensive psychiatric assessments, including presenting concerns, medical and psychiatric history, developmental and social context, mental state examination, risk assessment, formulation, treatment planning, and capacity. It is intended to support clear, organised communication with primary care colleagues.
Psychiatry
- Childhood Adversity Screening and Health Impact ReviewA structured template for documenting reported childhood adversity before age 18 and calculating a total ACE score. It also records the patient's reported perception of how these experiences have affected their overall health.
Psychiatry
- Psychiatry Initial ConsultationA reusable template for documenting a patient's initial psychiatric consultation. It covers the presenting concern, symptoms, psychosocial and clinical history, mental status examination, assessment, and treatment plan using only explicitly provided information.
Psychiatry
- Psychiatric Assessment – First AppointmentA structured template for documenting a first psychiatric assessment. It covers referral concerns, psychiatric and medical history, personal and family background, mental state, risk, formulation, diagnosis, management, and capacity and consent.
Psychiatry
- CBT SessionThis template structures documentation of cognitive-behavioural therapy sessions, including objectives, progress review, current patient concerns, cognitive and behavioural interventions, homework, and the plan for the next session. It supports consistent tracking of therapeutic work and patient progress.
Psychiatry
- Psychiatric Individual Therapy Intake NoteA reusable structure for documenting an individual’s initial therapy session, including presenting concerns, psychological, biological, and social factors, clinical assessment, risk, interventions, goals, and follow-up planning. It supports comprehensive assessment and individualized treatment planning without pre-populating any clinical information.
Psychiatry
- Comprehensive Psychiatric Assessment NoteA structured template for documenting comprehensive psychiatric consultations, including presenting concerns, psychiatric and medical history, substance use, family and legal history, mental status examination, and clinical recommendations. It supports clear, efficient recording of assessment and treatment planning information.
Psychiatry
- Inpatient Intake NoteA reusable inpatient admission documentation template for capturing the patient’s presenting concerns, psychiatric and medical history, medications, substance use, examination findings, safety considerations, assessment, treatment plan, and follow-up information. It is designed to support comprehensive documentation of complex inpatient cases.
Psychiatry
- Pediatric Behavioral Health Intake and Follow-UpA structured template for documenting pediatric behavioral health intake and follow-up visits. It covers presenting concerns, developmental and psychiatric history, medications, rating scales, mental status, safety, assessment, treatment planning, follow-up communication, billing, and care-team tasks.
Psychiatry
- Adult Autism Observation And Communication Assessment ReportA structured template for documenting an adult Autism Diagnostic Observation Schedule (ADOS-2) assessment. It covers referral context, developmental and behavioural information, observed social communication, ADOS-2 scoring, clinical formulation, recommendations, and follow-up.
Psychiatry
- Initial Autism Assessment ReportA structured template for documenting the initial phase of an autism assessment. It covers referral context, assessment methods, developmental history, clinical observations, relevant domains of functioning, preliminary formulation, risk, conclusions, recommendations, and capacity.
Psychiatry
- DARP Progress NoteA reusable DARP template for documenting mental health therapy sessions across Data, Assessment, Response, and Plan. It captures subjective and objective information, interventions, client responses, clinical progress, treatment goals, and follow-up actions.
Psychiatry
- Psychiatric Medication Review NoteA structured template for documenting a patient's current psychiatric medication regimen, including adherence, side effects, effectiveness, and concerns. It also organises the assessment, medication plan, education, testing, and follow-up information.
Psychiatry
- Sleep Disorder Follow-Up AssessmentA structured template for documenting follow-up care for patients with sleep disorders. It captures subjective sleep concerns, PAP therapy details, sleep and circadian patterns, daytime symptoms, objective findings, assessment, and the treatment plan.
Psychiatry
- Therapy and Medication Review NoteA reusable template for documenting psychotherapy sessions alongside medication management. It covers the patient’s concerns and progress, interventions, mental status findings, medications, safety, diagnostic and billing information, follow-up communication, and assigned tasks.
Psychiatry
- Follow-upThis psychiatric follow-up template structures documentation of ongoing care, including presenting complaints, mental status, risk, diagnoses, treatment, safety planning, and additional information. It supports consistent tracking of medication adherence, mood, cognition, and treatment progress across visits.
Psychiatry
- ADHD DSM-5 Diagnostic Criteria Documentation TemplateA structured template for documenting explicitly reported DSM-5 ADHD symptoms, supporting quotations, duration requirements, additional diagnostic conditions, and clinician-stated diagnostic classification. It covers inattentive, hyperactive/impulsive, combined, and predominantly presenting types without inferring unreported findings.
Psychiatry
- Medication ListA reusable medication-management template for documenting each medication’s names, class, indication, dosing, duration, side effects, benefits, dependence, and treatment response. It is suitable for organized medication tracking, including psychiatric care.
Psychiatry
- Follow-Up Letter to GPA concise letter template for updating a referring GP after a patient's psychiatric or mental health review. It captures the encounter's key findings and the agreed treatment plan to support continuity of care.
Psychiatry
- DIVA-5A structured template for documenting the DIVA-5 assessment of ADHD symptoms in adults and children. It covers inattentive and hyperactive-impulsive symptoms, developmental history, cross-setting presentation, functional impact, and alternative explanations.
Psychiatry
- Emergency Psychiatry ConsultationA structured template for documenting an emergency psychiatric consultation, including the presenting concern, clinical history, risk assessment, mental status examination, diagnostic impression, and care plan. It supports thorough, neutral documentation based only on the information provided.
Psychiatry
- Psychiatric Discharge NoteA structured template for documenting discharge after psychiatric or substance use treatment. It covers the reason for discharge, admission details, treatment progress, suicide risk, risk mitigation, discharge status, prognosis, and follow-up planning.
Psychiatry
- Psychiatry Progress NoteA concise structure for documenting psychiatric follow-up visits, including interim history, mental status, physical findings, investigations, clinical impression, and plan. It supports consistent recording of explicitly documented patient information without adding unstated details.
Psychiatry
- Psychiatric Inpatient Discharge SummaryA structured template for documenting a psychiatric inpatient admission from presentation through discharge. It covers the admission context, psychiatric and medical history, investigations, hospital course, discharge treatment, mental status examinations, diagnoses, medications, and follow-up planning.
Psychiatry
- DAP Progress NoteA reusable structure for documenting psychotherapy or mental health sessions using the Data, Assessment, and Plan format. It covers presenting concerns, mental status, interventions, responses, treatment progress, risk documentation, and next steps.
Psychiatry
- Progress NotesA reusable mental health progress-note structure for documenting patient identity, history, presentation, mental state, social and functional status, physical health, treatment planning, and follow-up. It is intended for comprehensive narrative documentation by psychiatrists, psychologists, and mental health nurses.
Psychiatry
- Psychiatric Ongoing Care Review NoteA structured template for documenting psychiatric follow-up reviews, including changes in history, symptoms, medication response, mental state, risk, capacity, clinical impression, and agreed plans. It supports consistent recording of ongoing care while preserving relevant updates and decisions.
Psychiatry
- Comprehensive Psychiatric AssessmentA structured template for documenting a detailed psychiatric evaluation, including referral context, presenting concerns, psychiatric and medical history, social factors, mental state, risk, clinical formulation, recommendations, and correspondence. It is designed to support complete, efficient documentation using only explicitly provided information.
Psychiatry
- Child ADHD Diagnostic Assessment TemplateA structured framework for documenting comprehensive ADHD assessments in children. It covers the assessment context, presenting concerns, developmental and psychosocial history, mental state and risk findings, child interview, Young Diva Questionnaire responses, and the discussion and care plan.
Psychiatry
- GAD-7 Anxiety AssessmentA structured template for documenting the GAD-7 anxiety questionnaire, including patient information, symptom-frequency scores over the previous two weeks, total score, anxiety severity, and the effect of symptoms on daily functioning.
Psychiatry
- Therapy NoteA reusable therapy-session documentation template for recording the patient’s presentation, concerns, progress, therapeutic topics and interventions. It also covers medications, safety assessment, follow-up communication, billing codes, and care-plan tasks.
Psychiatry
- Comprehensive Psychiatric IntakeA reusable template for documenting a comprehensive initial psychiatric evaluation. It covers presenting concerns, psychiatric and medical history, medications, psychosocial context, risk, mental status, diagnostic formulation, and the assessment and plan.
Psychiatry
- Psychiatric Assessment Update for GPA reusable English letter structure for psychiatrists communicating patient assessments, relevant history, diagnostic impressions, and management plans to a General Practitioner. It covers presenting concerns, mental state, substance use, psychosocial background, medications, and follow-up.
Psychiatry
- General Psychiatry New Patient AssessmentA reusable template for documenting an initial community-based psychiatry assessment in UK English. It covers medication and care planning, presenting concerns, psychiatric and medical history, substance use, family and personal history, mental state examination, discussion, and physical health parameters.
Psychiatry
- Psychiatric ConsultationThis template structures a comprehensive psychiatric assessment, covering patient identification, presenting illness, psychiatric and medical history, medications, substance use, family and legal history, mental status examination, and impressions with recommendations.
Psychiatry
- PHQ-9A structured template for administering and documenting the PHQ-9 depression questionnaire. It records each symptom score and timing, calculates the total score, assigns a depression severity level, and captures the functional impact of symptoms.
Psychiatry
- PCL-5This template structures the assessment of PTSD-related symptoms using the PCL-5 response scale. It covers trauma-related memories, avoidance, mood and cognition changes, arousal, reactivity, and sleep, while recording only explicitly provided or selected information.
Psychiatry
- C-SSRS AssessmentA structured template for documenting suicidal ideation, suicidal behavior, self-injurious behavior, preparatory acts, and suicide lethality. It supports consistent assessment of the presence, intensity, timing, and severity of suicide-related thoughts and actions using only explicitly provided information.
Psychiatry
- Initial Couples Psychiatric Assessment NoteThis template structures an initial couples therapy assessment, covering client and session details, consent, presenting concerns, psychological, biological, and social factors, clinical formulation, mental status, risk, and available strengths and resources.
Psychiatry
- Psychiatric Mental Status Assessment TemplateA structured template for documenting a comprehensive Mental State Examination across appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, and judgment. It supports consistent psychiatric assessments and mental health progress documentation.
Psychiatry
- Inpatient Progress NoteA reusable structure for concise inpatient psychiatric progress documentation. It covers admission background, clinical progress, record review, mental state, physical findings, risk, impression, and ongoing care planning.
Psychiatry
- Psychiatric Discharge SummaryA structured template for documenting psychiatric admissions and discharges, including patient identification, presenting illness, psychiatric and medical history, investigations, medications, mental status examinations, hospital course, discharge planning, and diagnoses.
Psychiatry
- Full Eating Disorder AssessmentA comprehensive template for documenting an eating disorder assessment, including presenting concerns, physical measurements, weight and eating history, mental state, risk, diagnosis, and treatment planning. It is designed for detailed clinical documentation based only on explicitly provided information.
Psychiatry