Comprehensive Psychiatric Evaluation Template

Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: _Friday 15th July 2022_______________________
Patient Initials: _M. K._____ Gender: M/F/Transgender _Female___ Age: _23 years____ Race: _White____ Ethnicity _Polish___
Reason for Seeking Health Care: _The patient was found unconscious but stable after taking an overdose of benzodiazepines and opioids. After receiving treatment for the drug overdose (the opioids belonged to her boyfriend), she agreed to receive professional treatment for her depressive and psychotic symptoms. Her sister accompanied her to the clinic. The patient reported that, “This is my third suicide attempt. My life has spiraled out of control and I want to get back on track. I have tried therapy before but it didn’t work. I am out of options now and I want to give it another shot”.
HPI:_Ms. Kozlowska is a 23-year-old white female who has been struggling with mental health issues since she was a teenager. The patient states that her depressive symptoms started around the time she was turning fifteen: “I remember becoming irritable and sad shortly before my fifteenth birthday. I would cry myself to sleep and often think of dying. Our father had recently passed away in a car accident, we were close you know. You know, he liked watching the Red Sox”. Her step-sister (45 years) chimed in: “Everyone expected my younger sister to be happy on her birthday. I remember our grandparents had flown in all the way from Poland and we were all excited for her. We spent a great deal of time decorating the house. We wanted her to be happy given how affected she was about the death of her father. I was thirty then and already married. I understood death. She didn’t. Turned out, she had no interest in her birthday and stayed miserable the whole day, no matter what we did. Her mood swings lasted for several weeks at a time after that. Chalked it down to being a spoiled American teenager”. The patient admits to not getting along with her mother or even her sister during that period: “Everyone thought I was acting all childish. My parents were immigrants who worked hard and true to raise us. My mother was very demanding and expected me to get straight A’s in school like my sister. I felt like the black sheep when I could not”. The patient reports that her periods of severe depression were followed by hyperexcitement: “I would steal my mother’s car and credit card during the weekend and hang out with my high school friends. We spent a lot on weed and booze during our frequent road trips. Oh, what jolly times they were”. The patient’s sister reports a time when they had to pay a hefty fine for her release after she was arrested for driving under the influence in another state. Their mother was so incensed that she grounded her for three months: “That’s when I thought about swallowing the bottle of antidepressants my mother kept in her medicine cabinet. She always thought she was so sleek with that blonde hair”. Although this attempt at killing herself was meant to “punish” her mother and make her “look bad”, Ms. Kozlowska admits to ingesting the Prozac pills becau...