Interview
Student Completing Form:
Hello, my name is _Jenny Flore Pierre______________ I am a psychiatric mental
health nurse practitioner & I’ll will preforming your intake today.
SECTION I: IDENTIFYING DATA (1–2 min)
• “Can I have your full name & DOB?” Avery Burgeron & 8/20/1982
• “What do you prefer to go by & what are your pronouns, if any?” Avery
• “How old are you?” 42 years old
• “What gender do you identify with?” Female
• “What is your cultural background or ethnicity? White
• “Who’s providing the information today? Is it yourself, and do you feel able to answer clearly?” Myself
SECTION II: CHIEF COMPLAINT (30 sec)
• "Can you describe what you've been experiencing, in your own words?"
Im sad, depress, lonely, hopeless. I need help!
History of Present Illness (Use OLDCART + Bold DSM
Symptoms): • Onset: When did you first start noticing these
symptoms? 3 months ago after Bob left me.
• Location: (If applicable) • Duration: How long do these last when they happen? 3 months ago.
• Character:
o What do your “highs” feel like? What kind of things do you do during
that time? Nothing
o What do your “lows” feel like? How do they affect your day-to-day life?
Depressed. Messing up at work, hard to concentrate and i dont want to
lose my job.
• Aggravating factors / Triggers: Are there certain events, stresses, or situations
that make it worse? Drinking
• Relieving factors: What helps you feel better? Sleep
• Timing: How often does this happen? Is there a pattern? All the time.
• Severity: How much does this affect your life—school, work, or relationships? Job: messing up. Cant concentrate @ work.
Psychiatric Review of Systems: “Okay, now I’m going to go through a series of
yes or no questions. Some of them might sound a little repetitive, but that’s just to
make sure we don’t miss
anything important. And if anything comes to mind while I’m asking, feel free to
stop me and share—it’s always helpful.”
(Ask and check off — if yes, ask for details. Reminder all positive findings must be
addressed in HPI.)
Mood (Depression)
No Have you had periods of feeling down or sad for more than 2
weeks? yes
Has this been going on for more than 2 years? No
Do you have trouble sleeping? No
Have you lost interest in things you normally enjoy? yes
Do you feel guilty or worthless? yes
Do you feel more tired than usual? yes
Is it harder to focus or concentrate? yes
Have you noticed changes in your appetite? yes
Have you been moving noticeably slower or faster than usual?
Yes
Have you had any thoughts of not wanting to be alive? No
Mania (Bipolar I/II)
☐ Yes ☐ No Have you had a period where you felt unusually high, energetic,
or irritable? If yes, how long did it last? _______________ NO
During those times, did you:
☐ Yes ☐ No Feel like you didn’t need much sleep? NO
☐ Yes ☐ No Talk more than usual or feel like you couldn’t stop talking? No
☐ Yes ☐ No Feel like your thoughts were racing?NO ☐ Yes ☐ No Get easily distracted? Yes
☐ Yes ☐ No Start lots of new projects or feel more goal-driven
than usual? NO
☐ Yes ☐ No Do anything risky (e.g., spending a lot of money,
unsafe sex)?NO
☐ Yes ☐ No Feel super confident or like you were invincible?
NO
Anxiety (GAD, Social, Panic)
☐ Yes ☐ No Do you often feel worried or nervous more days than not for at
least 6 months? NO
☐ Yes ☐ No Can you control or stop the worry, or does it take over? Takes over
Do you also experience:
☐ Yes ☐ No Feeling restless or on edge? NO
☐ Yes ☐ No Getting tired easily? Yes
☐ Yes ☐ No Trouble focusing? YEs
☐ Yes ☐ No Irritability? NO
☐ Yes ☐ No Muscle tension? NO
☐ Yes ☐ No Trouble sleeping? NO
Social Anxiety
☐ Yes ☐ No Do you avoid social events because you fear being judged or
embarrassed? ☐ Yes ☐ No Anxiety of performance? NO
☐ Yes ☐ No Does this interfere with work or relationships? YES
For how long? ____________
Panic Attacks ☐ Yes ☐ No Have you ever had a sudden rush of fear or discomfort that came out
of nowhere? If yes, did you experience: NO
☐ Yes ☐ No Fast heartbeat?
☐ Yes ☐ No Sweating?
☐ Yes ☐ No Shaking?
☐ Yes ☐ No Chest pain or discomfort?
☐ Yes ☐ No Shortness of breath?
☐ Yes ☐ No Choking feeling?
☐ Yes ☐ No Nausea/abdominal distress?
☐ Yes ☐ No Dizziness/lightheadedness?
☐ Yes ☐ No Chills/heat sensations?
☐ Yes ☐ No Tingling or numbness (paresthesia)?
☐ Yes ☐ No Derealization/depersonalization?
☐ Yes ☐ No Fear of losing control or dying?
OCD
☐ Yes ☐ No Do you have unwanted thoughts that keep repeating in your mind?
NO
☐ Yes ☐ No Do you feel the need to do certain things over and over to ease
those thoughts? NO
☐ Yes ☐ No Do these thoughts or actions take up more than an hour a day? NO
Insight: ☐ Good ☐ Fair ☐ Poor ☐ Absent
PTSD
☐ Yes ☐ No Have you experienced something traumatic? No
Do you:
☐ Yes ☐ No Have flashbacks? No ☐ Yes ☐ No Avoid people/places? NO
☐ Yes ☐ No Have amnesia about the event? NO
☐ Yes ☐ No Have negative self-beliefs? NO
☐ Yes ☐ No Feel guilt or shame? NO
☐ Yes ☐ No Experience anhedonia? NO
☐ Yes ☐ No Feel detached from others? NO
Alterations in arousal/reactivity:
☐ Yes ☐ No Irritability? NO
☐ Yes ☐ No Recklessness? NO
☐ Yes ☐ No Hypervigilance? NO
☐ Yes ☐ No Startle easily? NO
☐ Yes ☐ No Difficulty concentrating? NO
☐ Yes ☐ No Sleep disturbances? NO
Psychosis
☐ Yes ☐ No Have you seen or heard things that
others don’t? ☐ Yes ☐ No Paranoia NO
☐ Yes ☐ No Grandiose thoughts NO
☐ Yes ☐ No Somatic delusions NO
☐ Yes ☐ No Nihilistic beliefs NO
☐ Yes ☐ No Ideas of reference NO
☐ Yes ☐ No Obsessions NO
☐ Yes ☐ No Phobias NO
☐ Yes ☐ No Suicidal/Homicidal thoughts NO
☐ Yes ☐ No Magical thinking NO Perceptions:
☐ Yes ☐ No Illusions NO
☐ Yes ☐ No Depersonalization NO
☐ Yes ☐ No Derealization NO
Hallucinations:
☐ Auditory ☐ Visual ☐ Tactile ☐ Olfactory NO
Other Disorders
ADHD
☐ Yes ☐ No Trouble paying attention? Yes
☐ Yes ☐ No Difficulty performing
tasks? NO
☐ Yes ☐ No Fidgeting? NO
☐ Yes ☐ No Constantly “on the go”? NO
☐ Yes ☐ No Talks excessively? NO
☐ Yes ☐ No Trouble waiting their turn? NO
Eating Disorders
☐ Yes ☐ No Concerned about weight/body
image? NO
☐ Yes ☐ No Restrict, binge, or purge
behavior? NO
Suicide Risk Assessment ☐ Yes ☐ No Passive or active thoughts? NO
☐ Yes ☐ No Any plan? NO
☐ Yes ☐ No Intent to act? NO
☐ Yes ☐ No Past attempts? NO
☐ Yes ☐ No Current stressors? NO
☐ Yes ☐ No Protective factors? NO
☐ Risk Level: ☐ Low ☐ Moderate ☐ High LOW
☐ Yes ☐ No Homicidal thoughts? NO
Psychiatric History
• Have you ever been dx w a MH condition: Depression, anxiety
• Previously Tried Medications: No
• Previous Hospitalizations: NO
• Previous Counseling/Therapy: yes
• Previous Suicide Attempts: No
• Previous Non-Suicidal Self-Injury: NO
History of Trauma:
• Have you experienced something traumatic (abuse, violence, accidents,
loss)? NO
• Childhood trauma or dificult upbringing? Dad drinking
• Would you be comfortable sharing how this impacts you:
N/A
today? Substance Use; If yes, how much?
• Nicotine: __No________
• Caffeine/Energy: __1 cup coffee in AM________
• OTC/Supplements: _NO_________ • Alcohol: ___2 glass of wine a day_______
• Marijuana: _NO_________
• Illicit Drugs: _NO_________
• Prescription Drug Misuse: NO__________
Medical History
• Illnesses/Injuries: NO
• Last Medical Exam: NO
• Current Medications (Rx, OTC, Supplements): NO
• Allergies: NO
• Surgeries: NO
• LMP: May 10th
• Contraception: NO
Family History (Psych & Medical) : Pt doesnt have info about family history.
☐ Yes ☐ No Any family history of mental illness?
If yes, which family member and what diagnosis?
☐ Yes ☐ No Any family history of suicide or suicide attempts?
If yes, who and when?
☐ Yes ☐ No Any family history of substance use disorders?
☐ Yes ☐ No Any family history of major medical illnesses? (e.g., diabetes, heart
disease, cancer, thyroid disorders)
Additional notes on family dynamics or significant relationships: Developmental & Social History
• Who raised you? Mom and dad. Left home @ 17
• Any developmental delays, complications at
birth? NO
• Education level & school history: High school
• Work history: Retail
• Relationship status: Single
• Children: No
• Current living situation: Lives alone since Bob left
• Legal issues: NO
• Military History: NO
• Hobbies:
• Cultural & religious considerations: NO
Medical Review of Systems (if indicated)
• Constitutional:
___________________________ • HEENT:
_________________________________ •
Cardiovascular:
___________________________ •
Respiratory:
_____________________________ • GI:
___________________________________
_ • GU:
___________________________________
_ • Skin:
__________________________________ •
Neurological:
____________________________ •
Musculoskeletal:
__________________________
SECTION II / OBJECTIVE
Mental Status Exam (MSE)
• Appearance: _sad, depress, holding face with hand___________________________
• Orientation: ☐ Person ☐ Place ☐ Time Fully oriented
• Concentration: ☐ Intact ☐ Mildly Impaired ☐ Severely Impaired : Intact
• Manner: ☐ Cooperative ☐ Guarded ☐ Hostile ☐ Other: Cooperative
• Speech: ☐ Normal ☐ Pressured ☐ Slowed ☐ Loud ☐ Other: Normal
• Mood (subjective): Sad, depress
• Affect (objective): ☐ Full ☐ Restricted ☐ Flat ☐ Labile ☐ Other: ___ Flat
• Thought Process: ☐ Linear ☐ Circumstantial ☐ Tangential ☐ Disorganized ☐ Other: Linear
• Thought Content: ☐ Normal ☐ Obsessive ☐ Paranoid ☐ Delusional ☐ Suicidal ☐ Homicidal - Normal
• Perceptions: ☐ No hallucinations ☐ Auditory ☐ Visual ☐ Other: _______ No hallucinations
•Cognition & Memory: ☐ Intact ☐ Impaired (explain): _____________ Intact • Judgment: ☐ Good ☐ Fair ☐ Poor Good
• Insight: ☐ Good ☐ Fair ☐ Poor ☐ Absent Good
Physical Exam (if applicable)
☐ General Appearance: _Sad, depress, holding face with hand, appropriately dressed ________________________
☐ Neurological: Fully alert_______________________________
☐ Other systems: ______________________________
☐ N/A (Telehealth Visit)
Formulation / Diagnosis • ☐ Primary Diagnosis: Mood
depression________________________________ ☐
DSM Criteria: ☐ Met ☐ Unmet Met (Bold symptoms in
HPI)
Psychiatric Differential Diagnoses:
____________________ • ☐ Medical Differential
Diagnoses: No
Reflection / Self-Assessment (Post-Interview)
• ☐ What went well: I had my checklist prepared and
conversation with patient went in an orderly manner
• ☐ What would you improve? I’d give myself more time
to go more in depth about patients' answers to certains
important questions.
• ☐ What did you forget to ask or clarify? I got all the info i
needed for this intake.