What are the recommended questions to ask during an initial psychiatric intake?

Recommended Questions for Initial Psychiatric Intake

The American Psychiatric Association recommends that an initial psychiatric evaluation should include a comprehensive assessment of psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, risk assessment, and treatment planning. 1, 2

Identifying Information and Chief Complaint

• Document patient demographics (name, age, gender, date of birth), date and time of evaluation, and source of information 2
• Record the patient's own words regarding the presenting problem and circumstances leading to the evaluation 2

History of Present Illness

• Assess mood, level of anxiety, thought content and process, perception, and cognition 1
• Evaluate sleep patterns and abnormalities 2
• Document chronology of symptom development 2
• Use open-ended questions to gather information more effectively (e.g., "How have you been doing?", "What kinds of things have been on your mind or stressing you lately?") 1, 3

Psychiatric History

• Assess past and current psychiatric diagnoses 2
• Document previous psychiatric treatments (including types, durations, and doses) and patient's response to these treatments 1
• Evaluate adherence to past and current pharmacological and non-pharmacological psychiatric treatments 1
• Assess prior suicidal ideas, plans, and attempts (including context, method, damage, lethality, intent) 2
• Document prior aggressive behaviors or psychotic ideas 2

Substance Use History

• Evaluate patient's use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens) 1
• Assess any misuse of prescribed or over-the-counter medications or supplements 1
• Document current or recent substance use disorder or change in use of alcohol or other substances 1

Medical History

• Document allergies or drug sensitivities 1
• List all medications the patient is currently or recently taking and their side effects 1
• Assess whether the patient has an ongoing relationship with a primary care provider 1
• Document past or current medical illnesses and related hospitalizations 1
• Evaluate past or current neurological or neurocognitive disorders or symptoms 1
• Document physical trauma, including head injuries 1
• Assess sexual and reproductive history 1

Family History

• For patients with current suicidal ideas, assess history of suicidal behaviors in biological relatives 1
• For patients with aggressive ideas, assess history of violent behaviors in biological relatives 1
• Document psychiatric disorders in family members 2

Personal and Social History

• Assess presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems) 1
• Review the patient's trauma history 1
• Evaluate exposure to violence or aggressive behavior, including combat exposure or childhood abuse 1
• Document legal or disciplinary consequences of past aggressive behaviors 1
• Assess cultural factors related to the patient's social environment 1
• Evaluate patient's need for an interpreter 1
• Consider asking about early life adversity using tools like the Adverse Childhood Experience Questionnaire 1

Mental Status Examination

• Assess general appearance and nutritional status 1
• Evaluate coordination and gait 1
• Document involuntary movements or abnormalities of motor tone 1
• Assess sight and hearing 1
• Evaluate speech, including fluency and articulation 1
• Document mood, level of anxiety, thought content and process, perception, and cognition 1
• Assess hopelessness 1

Risk Assessment

• Evaluate current suicidal ideas, suicide plans, and suicide attempts, including active or passive thoughts of suicide or death 1
• If current suicidal ideas are present, assess:
  • Patient's intended course of action if current symptoms worsen 1
  • Access to suicide methods including firearms 1
  • Patient's possible motivations for suicide 1
  • Reasons for living 1
  • Quality and strength of the therapeutic alliance 1
• Assess current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide 1
• If current aggressive ideas are present, evaluate factors influencing risk 1

Quality of Life Assessment

• Use open-ended questions to assess how symptoms interfere with daily life: "How do your symptoms interfere with your ability to do what you want to do in your daily life?" 1
• Identify areas of life most affected by symptoms: "What areas of your life are affected most?" 1
• Explore patient's worries or concerns about their symptoms: "What worries or concerns do you have about your symptoms?" 1

Treatment Planning

• Ask about the patient's treatment-related preferences 1
• Provide an explanation of differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment 1
• Document the rationale for treatment selection, including discussion of specific factors that influenced the treatment choice 1
• Consider using quantitative measures of symptoms, level of functioning, and quality of life 1

Communication Approach

• Use open-ended questions to encourage patients to discuss their concerns freely, which has been shown to elicit more information 3
• Engage directly with patients' concerns about their psychotic symptoms rather than avoiding these topics, as this may improve satisfaction and engagement 4
• Position questions to allow patients to share their experiences rather than just verify information or make detached assessments of themselves 5