PSYCHIATRIC ASSESSMENT

 
Thank you for referring this patient to the [name of your service].

 

Reason for Referral

 

 

History of Presenting Complaint

 

 

Psychiatric History

 

 

Mental Health Act status

 

Voluntary

Recommendation for Assessment expires @

(the RA is the MHA2016 equivalent of R+R in MHA2000)

Treatment Authority

(the TA is the MHA2016 equivalent of ITO in MHA2000)

 

Substance Use

 

Alcohol

 

Tobacco

 

Cannabis

 

Amphetamines

 

Other Prescription/Illicit Drugs

 

Medical/Surgical

 

This Admission

 

 

History

 

 

Medication Allergies

 

 

Current Prescribed Medication (caution: medication list likely to be updated during admission. See medical discharge summary.)

 

 

Past Medications

 

 

Forensic History

 

 

Key Contacts

 

 

Collateral Information

 

 

Family History

 

 

Developmental History

 

 

Current Social Situation

 

 

On Review

 

 

Mental State Examination

 

Appearance -

Behaviour -

Speech -

Affect -

Mood -

Thought Form -

Thought Content -

Perception -

Cognition -          

Insight -

Judgement -

 

Estimated Risk

 

Self -

Others -

Vulnerability -

Absconding -

 

Impression/Formulation

 

 

 

Axis I (Primary Psychiatric Diagnosis)

 

Axis II (Personality and Intellectual Disorders)

 

Axis III (General Medical Conditions)

 

Axis IV (Psychosocial and Environmental problems)

 

Action

 

1.

 

2.

 

Plan

 

1.

 

2.

 

3.

 

 

Name

Role

Service

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