What is the appropriate psychiatric intake process for a 21‑year‑old patient?

Psychiatric Intake for a 21-Year-Old Patient

Begin the intake process by establishing a therapeutic alliance from the first telephone contact, clearly explaining the purpose of evaluation, treatment expectations, unit rules, and behavioral standards to both the patient and family, as this defuses potential crises caused by misperceptions and promotes personal responsibility. 1

Pre-Admission Preparation and Initial Contact

• Start building the therapeutic relationship during the intake telephone call by promoting personal responsibility and self-control, which permits a treatment environment where staff control is used only when patient self-control is unavailable or insufficient. 1

• Provide clear, developmentally appropriate explanations about the evaluation process, treatment goals, expected behaviors, and facility rules to both the patient and their family during initial contact. 1

• Use multimodal educational approaches including verbal discussion, written materials, and when applicable, role-playing or question-and-answer sessions to ensure understanding, as older adolescents and young adults respond better to interactive methods than passive information delivery. 1

• Obtain agreement from both patient and family to make every effort to abide by treatment recommendations and facility rules, as this reinforces their active role in treatment and improves outcomes. 1

Comprehensive Assessment Components

History of Aggressive Behaviors and Risk Assessment

• Document any history of aggressive behaviors toward self or others, including specific triggers, patterns (state vs. trait, reactive vs. proactive), and previous responses to interventions or medications. 1

• Review conduct problems systematically: stealing, fire-setting, cruelty to animals, sexually aggressive behaviors, low frustration tolerance, running away, tantrums, self-destructive behaviors, and substance abuse, as these provide critical information about dangerousness level. 1

• Assess physical characteristics that may impact treatment planning, including the patient's size, strength, and developmental status relative to peers, as these factors influence staffing needs and safety planning. 1

• Evaluate cultural and linguistic factors to ensure appropriate communication and avoid stereotyping or profiling based on race or culture when assessing risk. 1

Psychiatric and Medical Evaluation

• Conduct a thorough psychiatric assessment documenting current symptoms, psychiatric diagnoses, comorbidities, and functional impairment using standardized measures when possible. 1

• Screen for depression using validated instruments, as anxiety and other psychiatric symptoms in young adults are frequently manifestations of underlying depressive disorders. 1

• Assess suicide risk systematically by evaluating:

  • Current suicidal ideation, intent, and plan specificity
  • History of previous suicide attempts or self-harm (20.6% of gender-diverse youth report self-mutilation; 9.3% report suicide attempts) 2
  • Access to lethal means
  • Protective factors including family support and reasons for living
  • Recent stressors or triggering events 1

• Document baseline physical examination findings, including any preexisting abnormal movements, to avoid later mislabeling them as medication side effects if pharmacotherapy is initiated. 1

• Obtain baseline laboratory tests when medication trials are anticipated, including renal and liver function tests, complete blood counts, and electrocardiograms as indicated for specific agents. 1

Specialized Considerations for Gender-Diverse Patients

• Include sexual orientation and gender identity (SOGI) questions on intake forms, as 97% of patients are not distressed by these questions, and they facilitate gender-affirming care for the 3% who identify as gender-diverse. 3

• Use nonbinary-inclusive intake forms and electronic health records that allow patients to specify their affirmed gender identity, preferred name, and pronouns beyond binary male/female options. 4

• Be proactive in eliciting and consistently using preferred names and pronouns throughout all interactions, as misgendering and invalidation are frequent negative experiences even in clinics signaling transgender alliance. 4

• Assess for gender dysphoria (distress related to incongruence between experienced gender and sex assigned at birth) using developmentally appropriate questions, as this affects treatment planning and may require specialized referrals. 5, 6

• Document psychiatric comorbidities without assuming they are related to gender identity, as 44.3% of gender-diverse youth present with significant psychiatric history requiring additional mental health support. 2

Safety Planning and Risk Stratification

• Categorize suicide risk as low, moderate, or high based on:

  • Low risk: Transient ideation without intent or plan, responsive family, adequate impulse control
  • Moderate risk: Persistent ideation with vague plan, some family support, fair impulse control
  • High risk: Specific plan with intent, recent attempt, psychotic symptoms, poor impulse control, unsupportive family, substance use disorder, or severe functional impairment 1

• Arrange immediate mental health evaluation for moderate or high-risk patients through hospitalization, emergency department transfer, or same-day appointment with a mental health professional. 1

• Implement immediate safety measures including:

  • Removing all firearms from the home (adolescents can access locked guns)
  • Locking up all medications (prescription and over-the-counter)
  • Establishing 24-hour supervision for high-risk patients
  • Creating a crisis plan with specific contacts and steps 1

• Avoid relying solely on "no-harm contracts", as they have not been proven effective in preventing suicidal behavior, though refusal to agree is an ominous sign requiring higher level of care. 1

Treatment Planning and Disposition

• Determine appropriate level of care based on:

  • Severity of psychiatric symptoms
  • Suicide risk level
  • Functional impairment
  • Family support and ability to monitor
  • Substance use severity
  • Need for medication initiation or adjustment 1

• Arrange outpatient follow-up for low-risk patients with:

  • Specific appointment within 1 week
  • Clear crisis plan and emergency contacts
  • Family education about warning signs
  • Collaborative care coordination with mental health providers 1

• Consider psychiatric hospitalization for patients with:

  • Active suicidal ideation with plan and intent
  • Recent serious suicide attempt
  • Psychotic symptoms
  • Severe functional impairment (unable to leave home)
  • Inadequate family support or monitoring
  • Substance intoxication requiring medical management 1

Common Pitfalls to Avoid

• Do not minimize concerns from patients who joke about suicide or present with somatic complaints, as these may be their only way of asking for help and require thorough assessment. 1

• Do not assume lack of current suicidal ideation after a recent attempt indicates low risk if none of the precipitating factors have changed or the reasons for the attempt are not understood. 1

• Do not delay addressing trauma history, particularly for patients with history of physical or sexual abuse, as they may expect or unconsciously attempt to reproduce abusive situations and require specialized trauma-informed approaches. 1

• Do not proceed with treatment planning without ensuring the patient and family understand and endorse the treatment approach, as disagreement should prompt further discussion or referral to an alternative facility when possible. 1

• Do not overlook the need for staff training in normal development, psychopathology, risk factors for aggression, and cultural competency before implementing systematic intake procedures. 1