Child & Adolescent Psychiatric Diagnostic Evaluation Note

Date: [Encounter date and time]

Patient: [Name] | [DOB] | [MRN] | [Age at visit]

Clinician: [Name, credentials]

Location/Modality: [Setting] | [in-person / telehealth]

Participants and Information Sources

Present: [Youth name]; [Caregiver name(s) and relationship(s)] (Indicate if each was present for full visit or portions.)

Information Sources: [Sources used] (List only sources used: youth interview, caregiver interview, chart review, collateral contacts with roles, rating scales/structured tools.)

Reliability: [Reliability statement and limitations] (Comment on guardedness, interpreter use, pending collateral, placement-related gaps. State plan to obtain any pending information.)

Consent and Legal Status

• Legal Authority: [Person(s) with authority to consent; custody status if relevant] (Do not infer custody if unclear.)
• Youth Assent: [Assent obtained for interview]
• Confidentiality Discussion: [Confidentiality and limits explained to youth and caregiver, including safety concerns, mandated reporting, and court orders]
• Releases of Information: [ROIs signed or pending with targets and purposes]

Reason for Referral and Chief Complaint

Referral: [Referrer and reason for referral]

Chief Complaint: "[Direct quote capturing core concern]" — [Youth / Caregiver]

History of Present Illness

[Narrative of presenting concerns opening with the chief complaint, including onset and chronology, precipitating events, and contextual factors such as family changes, school transitions, trauma, or medical issues. Characterize symptoms across relevant domains using developmentally appropriate language.]

[Severity and functional impairment across settings: home, school, peers, activities. Include prior coping strategies and treatment attempts during this episode. Note evident strengths and protective factors.]

[Discrepancies between youth and caregiver reports] (Label differences explicitly without prematurely resolving them. Omit if reports are concordant.)

Psychiatric Review of Systems

(Document positive findings first, then key pertinent negatives that narrow the differential. Cover only clinically relevant domains. If abbreviated, note which domains will be completed at follow-up.)

• Mood/Depression: [Findings]
• Mania/Hypomania: [Findings]
• Anxiety: [Findings]
• OCD: [Findings]
• Trauma-Related: [Findings]
• Psychosis: [Findings]
• ADHD: [Findings across settings]
• Disruptive Behavior/Irritability: [Findings]
• Eating/Body Image: [Findings]
• Sleep: [Findings]
• Substance Use: [Summary; details in Substance Use History if positive]
• Self-Harm/Suicidal Ideation: [Findings; details in Safety Assessment]

Collateral and Rating Scales

(Include this section only if collateral contacts were made, rating scales were administered, or forms are pending; otherwise omit entirely.)

• Collateral: [Source name, role, organization] — [Method and date] — [Key information obtained]
• Rating Scales: [Instrument] | [Reporter] | [Date] | [Score and interpretation] | [How findings inform formulation]
• Pending: [Collateral or scales pending with plan to obtain]

Past Psychiatric History

• Prior Diagnoses: [Diagnoses] (Indicate established vs provisional.)
• Prior Therapy: [Types, duration, response]
• Prior Levels of Care: [Outpatient / IOP / PHP / residential / inpatient with dates if available]
• Hospitalizations/ED Visits: [Details]
• Medication Trials: [Name, dose range, duration, response, side effects, reason for discontinuation]
• Prior Self-Harm/Suicidal Behavior: [Brief summary; detailed current risk in Safety Assessment]
• Psychological/Neuropsychological Testing: [Dates and key conclusions]

Medical and Medication History

• Medical Conditions: [Active conditions]
• Surgical/Injury History: [Surgeries, significant injuries, concussion/TBI]
• Allergies/Adverse Reactions: [Allergies and ADRs]
• Current Medications: [Name, dose, schedule, indication, adherence] (Include supplements.)
• Vitals/Growth: [Height, weight, BMI, vitals] (Include if medications may be initiated.)
• Labs Reviewed: [Results with dates]
• Labs Ordered: [Tests ordered with rationale and monitoring plan]

Developmental History

• Pregnancy/Birth: [Prenatal exposures, labor/delivery, NICU course if applicable]
• Early Milestones: [Motor, speech/language development]
• Early Temperament/Regulation: [Feeding, sleep, irritability, soothability]
• Attachment/Separation: [History]
• Sensory/Repetitive Behaviors: [Findings] (Include if ASD in differential.)
• Social Communication/Adaptive Functioning: [Current level]
• Developmental Strengths: [Strengths and interests]
• History Limitations: [Gaps due to foster care/adoption/knowledge limitations; plan to obtain records] (Omit if history complete.)

Family History and Functioning

• Household Composition: [Members and caregiving arrangement]
• Family Psychiatric History: [First- and second-degree relatives]
• Family Substance Use: [History]
• Relevant Family Medical History: [Conditions]
• Family Functioning: [Parenting approaches, conflict patterns, communication, routines, caregiver stress/resources]
• Family Strengths: [Strengths and supports]
• Safety Concerns: [Domestic violence or other concerns] (Document sensitively. Omit if none.)

Social History

• Living Situation: [Stability, housing/food security]
• Peer Relationships: [Quality and social support]
• Bullying: [In-person and online experiences]
• Romantic/Sexual Relationships: [Age-appropriate details]
• Cultural/Identity Factors: [Cultural, faith, community context; relevant identity factors]
• Activities/Interests: [Activities, exercise, extracurriculars]
• Trauma/Adversity: [Exposure history] (Use trauma-informed language.)
• Legal/Child Welfare: [Involvement] (Omit if none.)
• Firearms Access: [Presence in home and storage practices]
• Adolescent Privacy: [Note if history obtained privately; confidentiality limits reviewed] (Include for adolescents.)

School and Learning

• Current Placement: [Grade and school]
• Attendance: [Patterns and concerns]
• Academic Performance: [Trajectory and current functioning]
• Classroom Behavior: [Observations and teacher concerns]
• Learning Concerns: [Difficulties and prior evaluations]
• IEP/504: [Status and accommodations]
• Disciplinary History: [Incidents]
• Social Functioning at School: [Peer interactions, bullying, school refusal]
• School Strengths: [Strengths and supportive staff]
• School Coordination Plan: [ROI status and planned actions]

Substance Use History

(Required for adolescents. Note if history is incomplete due to limited youth interview.)

• Screening: [Nicotine/vaping, alcohol, cannabis, stimulants, opioids, hallucinogens, inhalants, Rx misuse]
• Use Details: [For each substance: frequency, quantity, route, last use, consequences]
• Context: [History obtained privately with youth: yes/no; confidentiality reviewed]
• Interventions: [Harm reduction counseling provided; referrals made]

Mental Status Examination

• Appearance/Behavior: [Grooming, dress, eye contact, motor behavior]
• Speech: [Rate, rhythm, volume, tone]
• Psychomotor: [Activity level]
• Mood: "[Youth's words]"
• Affect: [Quality, range, congruence, stability]
• Thought Process: [Coherence, organization]
• Thought Content: [Preoccupations, obsessions, delusions; SI/HI noted here, details in Safety Assessment]
• Perceptions: [Hallucinations, illusions]
• Cognition: [Orientation, attention, memory] (Developmentally appropriate.)
• Insight: [Level]
• Judgment: [Level]
• Impulse Control: [Level]
• Reliability/Engagement: [Assessment]
• Developmental Observations: [Play behavior, separation behavior, social reciprocity] (Include for younger children.)
• Limitations: [Observational constraints if any]

Safety and Risk Assessment

Suicide Risk: [Current ideation: none / passive / active] | [Plan: none / vague / specific] | [Intent: none / low / high] | [Preparatory behaviors] | [Access to means] | [Past attempts and self-harm] | [Protective factors: reasons for living, supervision, treatment engagement]

Violence/Homicide Risk: [Ideation, identified targets, access to weapons, history of aggression, protective factors] (Include if clinically relevant.)

Abuse/Neglect Concerns: [Concerns identified; mandated report made to (agency) on (date); safety plan implemented] (Include only if concerns present.)

Risk Level: [low / moderate / high] — [Clinical reasoning supporting this assessment]

Disposition: [Outpatient / Urgent referral / ED evaluation / Inpatient] — [Rationale]

Safety Plan: (Include for outpatient disposition when risk factors present.)

• Warning Signs: [Individual warning signs identified]
• Coping Strategies: [Skills and calming techniques]
• Support Contacts: [People to contact; supervision plan]
• Crisis Resources: [Resources provided: 988, Crisis Text Line, local crisis services]
• Lethal Means Counseling: [Actions agreed upon]
• Contingency Plan: [Plan if symptoms worsen]

Diagnostic Formulation and Impression

Clinical Summary: [Age, presenting concerns, duration, key impairments, salient risk and protective factors]

Formulation: [Biopsychosocial and developmental formulation addressing predisposing factors (genetic, temperament, neurodevelopmental), precipitating factors, perpetuating factors, and protective factors]

Differential Diagnosis: [Top considerations with brief justification]

Diagnoses:

• [Diagnosis] ([ICD-10 code]) — [confirmed / provisional] (If provisional, specify data needed to confirm.)

Severity/Acuity: [Statement supporting level of care and disposition]

Treatment Plan

(Organize by problem when multiple issues are addressed.)

[Problem]: [Target symptoms/diagnosis]

Assessment: [How symptoms cause impairment and relate to diagnosis]

• Psychoeducation/Shared Decision-Making: [Working diagnosis explained; treatment options discussed; youth/caregiver preferences]
• Safety Interventions: [Safety plan elements; crisis resources; lethal means counseling; supervision plan] (Include if risk factors present.)
• Psychotherapy: [Modality; frequency; referral status]
• Family/Systems Interventions: [Parenting support; family therapy; home-based recommendations]
• School Interventions: [ROI; teacher rating scales; accommodation considerations; coordination plan]
• Medication: [Indication linked to target symptoms; medication and rationale; start/titration plan; monitoring plan; risks/benefits discussed] (Include only if prescribing.)
• Labs/Referrals: [Tests or referrals ordered with rationale]

Watchful Waiting: [Rationale and triggers for escalation] (Include if active treatment deferred.)

Follow-Up: [Timing and interval rationale] — [Specific items to reassess: pending collateral, diagnostic uncertainty, treatment response, safety]

Signature

[Clinician signature, credentials]