Psychiatric Follow-Up Note Form
Document a psychiatric follow-up visit, including current symptoms, mental status, medication review, risk assessment, and treatment plan.
Patient & Visit Details
Patient Name
*
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-Up Visit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Visit Time
*
Hour Minutes
AM
PM
AM/PM Option
Provider/Clinician Name
*
Visit Type / Setting
*
In-person
Telehealth
Phone
Interval History & Current Status
Reason for follow-up / interval changes since last visit
*
Current primary psychiatric concerns or symptoms
*
Symptom severity
*
1
2
3
4
5
Sleep, appetite, and energy changes
No significant change
Sleep decreased
Sleep increased
Appetite decreased
Appetite increased
Energy decreased
Energy increased
Other
New stressors or major life events since last visit
Mental Status & Risk Assessment
Mental status examination
*
Rows
Orientation
Appearance
Behavior
Mood
Affect
Thought process
Thought content
Within normal limits
1
2
3
4
5
6
7
Mildly abnormal
8
9
10
11
12
13
14
Moderately abnormal
15
16
17
18
19
20
21
Severely abnormal
22
23
24
25
26
27
28
Unable to assess
29
30
31
32
33
34
35
Suicide risk
*
None
Passive thoughts
Active thoughts
Plan/intent
Unable to assess
Self-harm risk
*
None
Passive thoughts
Active thoughts
Plan/intent
Unable to assess
Homicidal ideation
*
None
Passive thoughts
Active thoughts
Plan/intent
Unable to assess
Hallucinations
*
None
Auditory
Visual
Other sensory
Unable to assess
Delusions
*
None
Present
Suspected
Unable to assess
Safety concerns
*
None
Mild
Moderate
Severe
Unable to assess
Safety plan / protective factors
Medication Review
Current psychiatric medications
*
Medication adherence
*
Takes as prescribed
Mostly takes as prescribed
Sometimes misses doses
Rarely takes as prescribed
Not applicable
Medication side effects
Drowsiness
Nausea
Dizziness
Weight gain
Tremor
Dry mouth
Insomnia
GI upset
Sexual side effects
Other
Recent dose changes
Medication refills requested
No refills needed
Refill for current medication(s)
Dose clarification needed
Pharmacy change requested
Other
Treatment Plan & Follow-Up
Assessment / Clinical Impression
*
Plan of Care
*
Patient Education Provided
Medication adherence
Side effects discussed
Therapy recommendations reviewed
Laboratory tests discussed
Referrals discussed
Safety plan reviewed
Other
Follow-Up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Next Appointment Instructions
Submit Note
Should be Empty: