Chief complaint: HISTORY OF PRESENT ILLNESS: Mood in the last month: Depression: Irritability/anger/ aggressive behaviors: Euphoria: Interests: Worthlessness/hopelessness/inappropriate guilt: Energy: pt reports “

Concentration: Appetite: Psychomotor: Sluggish_ Sleep: Suicidality/self harm/thought about death: Distractability? Indiscresion/impulsive: Grandiosity (big shot, arrogance, or invincibility): Flight of Ideas:. Activity increase/pressured speech/ Tangential?: Sleep need decreased: ; restless_

or substance use? SUBSTANCE USE: Current use: Past use: PAST PSYCHIATRIC HISTORY: . PD.These symptoms in the past: __________________________________________ Do you ever feel anxious or worried? Most days every day? Disruptive to daily life? Are there times that your anxiety feels worse than worrying/when/what happens? Trigger?: Worry about having another?: TRAUMA:/ Environmental factors effect pt’s life/illness: Recurrent thoughts about the incident. IOR. vividdaydreaming or nightmares about trauma/environmental factors? Avoidance of related stimuli? Numbness to event or emotions at time of event: Memory loss: denies Easily startled: Perceptual AH. anger. fixed delusion or delusions of Grandeur? Black outs from anxiety. VH. OH. re-expreiencing.

Outpatient care? Inpatient care?: Current meds?: none Medical meds? Last physical/pregnancy: Past Meds tried: Current treatment: Supports/ current living situation: System Involvement: Family Constellation: Biological Family History: Medical illness or injury: MENTAL STATUS EXAM: Appearance/affect: Behavior: amiable and cooperative. Alertness: a and o x 3 Speech: normal tone. No pressured speech. Mood: “ Thought Process: clear linear goal directed Perceptions: wnl Judgment/Impulse Control: good Denies. rate. and rhythm. . Pt appears calm and organized.

Insight: partial Cognition: memory and abstract thinking intact. . pt is aware of medication risks and benefits. Suicidal/Homicidal: denies BIO/PSYCHO/SOCIAL AND RISK FORMULATION (S): Axis Axis Axis Axis Axis Axis Axis I (primary): I (other): II: deferrred III: IV: V (current): V (highest in past year): RISK ASSESSMENT (per scale): Suicide: Violence: Addiction: Medication prescribed this meeting: PLAN: Safety: continue to mx for safety and efficacy.

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