By Daniel Akselrod · Licensed Attorney · July 2026

Intake Forms for Psychiatrists: Medication History, Diagnostic Screening, and Risk Assessment

A psychiatrist’s intake is not a therapist’s intake with a medication list bolted on. The two disciplines share a patient population but serve fundamentally different clinical functions, and their intake forms should reflect that difference. A therapist needs to understand the patient’s narrative — their relationships, their coping patterns, their goals for treatment. A psychiatrist needs to understand the patient’s neurobiology — what medications have been tried, at what doses, for how long, with what response, with what side effects, and why they were discontinued. That medication trial history is the foundation of every prescribing decision, and capturing it properly at intake saves the psychiatrist from spending the first appointment reconstructing a pharmacological timeline that the patient remembers imprecisely.

A purpose-built psychiatric intake form captures what the psychiatrist actually needs to make clinical decisions: structured medication history, medical comorbidities that affect prescribing, substance use that interacts with psychotropic medications, diagnostic screening data, and risk assessment. Here is what each of those sections should contain and why it matters.

Medication history: the most important section on the form

A patient who says “I’ve tried antidepressants before and they didn’t work” is giving you almost nothing clinically useful. Which antidepressant? What class — SSRI, SNRI, tricyclic, atypical? What dose? Was the dose titrated to the therapeutic range, or did the prescriber stop at the starter dose? How long was the trial — two weeks (too short to evaluate an antidepressant) or twelve weeks (an adequate trial)? What was the response — no improvement, partial improvement, or full remission followed by relapse? What side effects occurred, and were they tolerable or treatment-limiting? Why was it discontinued — side effects, lack of efficacy, cost, loss of insurance, or the patient decided to stop?

Every one of those questions changes the prescribing decision. A patient who failed adequate trials of two SSRIs (sertraline at 200mg for eight weeks, escitalopram at 20mg for eight weeks) has treatment-resistant depression by clinical definition, and the next step is augmentation, switching class, or considering interventional options. A patient who took sertraline 25mg for three weeks and quit because of nausea has not failed an SSRI trial — they had a subtherapeutic dose for an inadequate duration with a common initial side effect that usually resolves.

Your intake form should capture, for each prior psychiatric medication:

• Medication name and class — generic and brand, because patients often know one but not the other
• Maximum dose reached — not the starting dose, the highest dose the patient actually took
• Duration of treatment — at the maximum dose, not total time on the medication. A patient who took 50mg of sertraline for four months and then 100mg for two weeks had a two-week trial at 100mg, not a four-month trial
• Clinical response — no response, partial response, full response, or initial response that faded
• Side effects experienced — specific effects, not “side effects.” Weight gain, sexual dysfunction, insomnia, sedation, GI distress, emotional blunting, and akathisia are all different problems with different implications for the next medication choice
• Reason for discontinuation — this is distinct from side effects. A patient may have had a good response with manageable side effects but stopped because they lost insurance coverage. That medication might be the right one to restart
• Prescriber — was it prescribed by a psychiatrist, a primary care physician, a nurse practitioner, or someone else? This provides context about the sophistication of the prior treatment plan

This section is where psychiatric intake forms need the most space. A patient with a long treatment history may have tried eight or ten medications across multiple classes. A form that provides three lines for “current medications” is not going to capture that history.

Medical comorbidity: the conditions that change prescribing

Psychiatry is a medical specialty, and psychiatric medications are systemic drugs that interact with the rest of the body. A psychologist’s intake form captures medical history for context. A psychiatrist’s intake form captures medical history because it directly constrains prescribing decisions.

• Thyroid function — hypothyroidism mimics depression. Hyperthyroidism mimics anxiety and mania. Lithium causes hypothyroidism as a side effect. A patient presenting with depressive symptoms who has never had a thyroid panel needs one before starting an antidepressant, because treating a thyroid problem as depression is a misdiagnosis, not a treatment failure.
• Cardiac history — QTc prolongation is a potentially fatal side effect of several psychotropic medications, including citalopram at doses above 40mg, some antipsychotics (ziprasidone, thioridazine), and tricyclic antidepressants. A patient with a history of arrhythmia, congenital long QT syndrome, or cardiac conduction abnormalities has a restricted medication menu. The intake should ask about heart conditions, palpitations, fainting episodes, and family history of sudden cardiac death.
• Hepatic and renal function — the liver metabolizes most psychotropic medications, and the kidneys excrete lithium. A patient with liver disease or chronic kidney disease may need lower doses, different medications, or more frequent lab monitoring. The intake should ask about liver disease, kidney disease, and current lab work.
• Seizure history — bupropion lowers the seizure threshold. Clozapine lowers the seizure threshold. Some benzodiazepines are prescribed specifically for seizure disorders. A seizure history changes both the risk profile and the potential benefit of specific medications.
• Pregnancy and reproductive status — many psychotropic medications are teratogenic or have inadequate safety data in pregnancy. Valproate is a known teratogen. Lithium carries cardiac risks in the first trimester. The intake must capture pregnancy status, breastfeeding status, and contraceptive use in patients of childbearing potential, because these factors affect prescribing from day one.
• Autoimmune and neurological conditions — lupus, multiple sclerosis, and other autoimmune conditions can present with psychiatric symptoms. Neurological conditions like Parkinson’s disease interact with dopaminergic medications. The intake should capture these diagnoses so the psychiatrist can distinguish primary psychiatric illness from secondary psychiatric symptoms caused by a medical condition.

Substance use screening: what the patient may not volunteer

Substance use interacts with psychiatric medication in ways that range from reduced efficacy to lethal overdose risk. Alcohol potentiates benzodiazepines. Stimulant use complicates ADHD treatment. Cannabis can exacerbate psychotic symptoms. Opioid use affects pain management decisions and benzodiazepine prescribing risk. A patient who is actively using substances needs a different treatment plan than one who is not — not a judgment, a clinical reality.

Your intake form should screen for current and past use of alcohol (quantity and frequency, not just “do you drink”), cannabis, stimulants (cocaine, methamphetamine, prescription stimulant misuse), opioids (heroin, fentanyl, prescription opioid misuse), benzodiazepine misuse, nicotine, and any other substances. It should also capture any history of substance use treatment — detox, residential treatment, outpatient programs, medication-assisted treatment (methadone, buprenorphine, naltrexone) — because that history informs the current treatment approach.

The intake form is not an interrogation. Frame the questions neutrally and explain that the information affects medication safety. Patients are more forthcoming when they understand that the question is about drug interactions, not moral judgment.

Diagnostic screening: structured data the psychiatrist can use

A patient’s self-reported symptoms are valuable but subjective. Structured screening instruments give the psychiatrist a standardized baseline that can be tracked over time to measure treatment response. Your intake form should either incorporate or reference the validated instruments that are standard in psychiatric practice:

• PHQ-9 — nine-item depression severity scale. Score of 10+ suggests moderate depression. Takes two minutes to complete. Repeatable at every visit to track response to treatment.
• GAD-7 — seven-item anxiety severity scale. Score of 10+ suggests moderate anxiety. Same logic as the PHQ-9 — baseline at intake, repeated at follow-up to quantify improvement.
• MDQ (Mood Disorder Questionnaire) — screens for bipolar spectrum disorders. This is critical because a patient presenting with depression who actually has bipolar disorder should not be started on an antidepressant alone — antidepressant monotherapy can trigger mania in bipolar patients. Catching this at intake prevents a prescribing error.
• AUDIT-C or CAGE — alcohol use screening. Complements the substance use section with a validated instrument.
• Adult ADHD Self-Report Scale (ASRS) — if the patient is presenting with attention or concentration complaints, this screener helps distinguish ADHD from other causes of cognitive difficulty (depression, anxiety, sleep deprivation, substance use).

Risk assessment: the section that protects the patient and the practice

Every psychiatric intake must include a risk assessment. This is not optional, and it is not something that can wait for the first appointment. If a patient discloses active suicidal ideation on the intake form, the practice needs to know before the appointment so the clinical team can triage appropriately.

Your intake form should ask directly about current and past suicidal ideation (passive thoughts of death, active thoughts of suicide, plan, intent, means access), self-harm behaviors, homicidal ideation, history of psychiatric hospitalization, and history of suicide attempts. These questions should use clear, clinical language — not euphemisms. “Have you had thoughts of ending your life?” is clear. “Have you been feeling down?” does not screen for suicidality.

The Columbia Suicide Severity Rating Scale (C-SSRS) is widely used for structured suicide risk assessment and can be incorporated into or referenced by the intake form. Some practices include the C-SSRS screener as part of the intake packet; others administer it verbally at the first appointment. Either way, the intake form should capture enough risk information to identify patients who need expedited appointments or immediate safety planning.

Insurance and prior authorization: the prescribing constraint nobody talks about

In practice, the insurance formulary is as much a constraint on prescribing as the clinical evidence. A psychiatrist who determines that a patient should try aripiprazole as an augmentation agent may find that the insurance plan requires a prior authorization, a step therapy protocol (fail generic alternatives first), or does not cover the medication at all. Capturing the patient’s insurance information and formulary tier at intake lets the practice check coverage before the appointment, so the psychiatrist can discuss realistic medication options rather than writing a prescription that the pharmacy will reject.

The intake should also capture the patient’s pharmacy preference and whether they are open to mail-order pharmacy (which often has lower copays for maintenance medications), whether they have a prescription discount program, and whether cost is a significant factor in medication adherence. A patient who stops taking a medication because they cannot afford the copay is not experiencing a treatment failure — they are experiencing an access problem, and the intake is where that problem gets identified.

Building the clinical foundation

A thorough psychiatric intake form is the clinical foundation for every prescribing decision that follows. It captures the medication trial history that determines what to try next, the medical comorbidities that constrain what is safe, the substance use that affects drug interactions, the diagnostic screening data that establishes a measurable baseline, and the risk assessment that protects the patient from harm. None of this is optional, and none of it is captured by a generic medical intake form.

The Templateez psychiatry intake form is designed for this level of clinical specificity: structured medication trial tables, medical comorbidity screening, substance use assessment, diagnostic instrument integration, and risk assessment fields, all in a fillable PDF that patients can complete before their first appointment.