What Is an Psychiatric Intake Template?

Psychiatric care involves getting a sense of a large picture in order to diagnose, assess safety, launch treatment, and set the tone for long-term care. An intake template structures this into something legible. It captures the entire clinical picture: from symptoms and meds to trauma, substance use, family context, and DSM-5 criteria

When Should You Use a Psychiatric Intake Template?

Use this template for:

• Initial psychiatric evaluations
• Transfers into new levels of care (e.g., outpatient, IOP, residential)
• Re-establishing care after a long lapse
• Diagnostic clarification visits
• Building documentation for treatment planning or insurance

This applies across psychiatry, telepsych, collaborative care models, and complex primary care.

How Should You Use the Intake Template?

The intake template is high-density and multi-domain. It organizes:

• Presenting concerns (Summary, Chief Complaint)
• The story (HPI)
• Systems context (Social, Family, Psychiatric histories)
• Substance use and sleep
• Mental status + safety
• Diagnosis, plan, and tasks

Used properly, it reflects the totality of institutional care, including safety protocols, medication access, team communication, and custodial/legal involvement.

Key Sections of the Intake Template

Summary & Chief Complaint

• Summary: One-line synopsis of today’s evaluation
• Chief Complaint: The patient’s framing of why they’re seeking help

Clinician Tip

Let the patient lead here, even if you suspect there's more to the story. Contrasting the CC with the observed symptoms often reveals diagnostic nuance.

History of Present Illness (HPI)

This is the core narrative:

• Symptom onset and progression
• Functional impairment
• Coping strategies, prior treatments
• Current stressors
• Insight, motivation, and goals

Clinician Tip

Think chronologically. When did this begin? What changed? Why now?

Medications & Access

• Meds currently prescribed (psychiatric and non-psychiatric)
• Side effects, adherence, efficacy
• Access issues (insurance, pharmacy, cost barriers)

Clinician Tip

Note any med changes since the last provider or facility—especially if the patient doesn't know why something was discontinued.

Psychiatric, Social & Family History

Psychiatric History

• Past diagnoses, hospitalizations, suicide attempts
• Treatment adherence and outcomes

Social History

• Housing, employment/school, relationships, stressors
• Cultural or spiritual factors that may shape care

Family History

• Psychiatric conditions in immediate or extended family
• Suicide, bipolar disorder, schizophrenia, substance use

Substance Use & Sleep

Substance Use

• Substances used, route, frequency, duration
• Last use
• Treatment history (e.g. rehab, MAT)

Sleep

• Onset latency, maintenance, duration
• Hypersomnia or insomnia
• Sedation from meds

Tests and Scores

Include any structured scales:

• PHQ-9, GAD-7
• ASRS, PCL-5, YMRS, etc.

Mental Status Exam (MSE)

Document objective findings:

• Appearance and behavior
• Mood and affect
• Thought process/content
• Perceptions
• Cognition
• Judgment and insight

Safety Assessment

Essential in all intakes. Include:

• Current suicidal/homicidal ideation
• Past attempts, self-injury, violence
• Access to lethal means
• Protective factors
• Psychiatric advance directives or safety plans

DSM-5-TR Codes & Assessment

List:

• Diagnoses using DSM-5 terminology
• ICD-10 codes for billing and documentation
• Brief justification for each diagnosis (symptom criteria, duration, impairment)

Plan

The next steps in treatment. Include:

• Medication changes or initiations
• Referrals (therapy, labs, case management)
• Safety interventions
• Behavioral goals
• Psychoeducation

Clinician Tip

Make the plan clear enough that another clinician reading the note could continue care.

Follow-Up & To-Dos

• Recommended return time
• Lab or imaging orders
• Tasks for clinician or staff
• Tasks for patient

What Is an AI Scribe?

An AI scribe is an automated tool to simplify the process of note-taking and documenting patient encounters. An AI scribe will automatically convert rough notes into a structured record of the intake, documenting the specifics and filling out a template for you. The goal is that you handle the ideas and encounter, and the AI tackles the procedure.

JotPsych’s Intake Note Template

What It Is

JotPsych’s intake template is tailored for acute psychiatric care. It includes:

• Presenting problems
• Psychiatric and substance use history
• Sleep and functioning
• Family/social/legal context
• Safety and DSM-5 diagnosis
• Plan and billing-ready outputs

How It Works

Before a patient encounter, you open JotPsych, select your psychiatric intake template, and begin recording. The template has every section you should need in your intake, but can be easily customized if you find your encounters taking a different shape. To see how to create your first note, click here, and to see how to customize a template, click here.

When your encounter concludes, simply finish recording in JotPsych. Our AI will autopopulate the template with the relevant parts of your discussion, turning the conversation into notes automatically.

To see what a sample encounter looks like and how JotPsych turns any recording into a comprehensive note, click below.

Benefits of the Intake Template

• Covers all relevant systems without forgetting key elements
• AI identifies and organizes info across psychiatric and social domains
• Captures risk, diagnosis, and plan in an audit-ready format
• Saves you time—no more backfilling after the interview
• Designed to meet clinical and billing standards

Customizing the Template

If your unit requires different fields—like trauma history, legal status, collateral info—you can modify the template and JotPsych will respect that structure moving forward. To learn how to customize JotPsych Templates, click here.

FAQ

Is submitting recordings to JotPsych secure?

Yes, it is! JotPsych takes extensive measures to remain HIPAA compliant and uses secure encryption to maintain the integrity of patient data.

Why does intake documentation need its own template?

This one is built specifically for psychiatric evaluation—with fields for mood, psychosis, substance use, risk, and DSM-5 diagnoses. It balances comprehensiveness with speed, and it's optimized for use with AI so your documentation doesn’t drag behind your clinical work.