INTEGRATIVE
PSYCHIATRY

Douglas Zelisko, M.D. • Board Certified Psychiatrist

45 South Main Street Suite 111, West Hartford, CT 06107
P: 860.615.3629  |  F: 860.318.2085  |  E: support@drzelisko.com

Pre-Intake Psychiatric Brief

Pre-Intake Psychiatric Brief

Celia Smth

Provider-facing pre-intake briefing with structured risk, symptom, psychometric, and first-visit priorities.

DOB / Age

08/12/1978 (age 47)

Client ID

0376

Date of Service / Intake

Headway intake completed 07/31/2026

Document Type

Pre-Intake Summary

Executive Snapshot

Primary presentation: 47-year-old married Hispanic/Latina woman presenting for ongoing treatment of OCD and ADHD, described as lifelong and severe, with difficulty initiating and completing tasks despite current medication treatment.

Clinical complexity: Current concerns are best understood in the context of established OCD and ADHD diagnoses, partial medication response, intermittent panic/anxiety attacks, fatigue, past sleep disturbance, grief related to her mother’s death, past physical/verbal abuse, and family history notable for maternal anxiety, depression, suicide, and possible bipolar disorder.

Patient goal: Continued growth, improved task completion, and sustained management of OCD and ADHD symptoms.

Immediate Risk Snapshot

  • Safety: She endorsed past thoughts of killing or harming herself but denied suicide attempts. PHQ-9 item 9 was marked not at all. Current suicidal ideation, plan, intent, means access, homicidal ideation, protective factors, and crisis supports require direct confirmation.
  • Sleep/medication safety: She endorsed sleep concerns overall and a past history of sleeping too little or too much, while denying current difficulty falling or staying asleep. Current sleep schedule, total duration, quality, snoring, apnea symptoms, stimulant timing, and daytime impairment require clarification.
  • Family/social risk context: Unemployed, married for 10 years, and living in adequate housing. Significant contextual factors include her mother’s death approximately five years ago, past physical/verbal abuse, intermittent panic/anxiety attacks, and current difficulty completing tasks.
  • Substance context: Reports alcohol use but entered 0 drinks/day, states use over many years, and denied a need to cut down. Prescription amphetamine use was endorsed. Other listed substances were not endorsed. Clarify actual alcohol frequency, last use, stimulant use as prescribed, caffeine, nicotine, cannabis, and other substance exposure.

First 10 Minutes

Clarify: Establish a collaborative transfer-of-care frame, confirm current safety, clarify the patient’s goals for continued treatment, and understand what has and has not worked in prior OCD and ADHD care.

Diagnostic Focus

Differentiate: Clarify the current severity and functional impact of OCD and ADHD, distinguish residual symptoms from medication side effects, anxiety, grief, sleep, thyroid dysfunction, migraines, PCOS, and possible bipolar-spectrum vulnerability, and determine whether treatment optimization is appropriate.

Treatment Planning

Prioritize: Prioritize safety review, medication reconciliation, current OCD symptom characterization, ADHD functional assessment, review of panic/anxiety attacks, thyroid and medical status, sleep and stimulant timing, and coordination with prior prescriber records.

Psychometrics

PHQ-9 4/27

Minimal depressive symptom severity. Endorsed symptoms include some sleep change, low energy, and self-critical thoughts; item 9 was marked not at all. The low score does not eliminate the need to clarify past suicidal thoughts and grief history.

GAD-7 1/21

Below the usual threshold for generalized anxiety disorder on this measure. However, the intake separately documents intermittent panic/anxiety attacks and constant worrying, so symptom-specific assessment remains warranted.

ASRS / ADHD Screening No standardized ADHD rating scale documented in the available intake.

ADHD was reported as diagnosed last year and is currently treated with Adderall XR 30 mg. The patient reports Adderall works well but Adzenys XR worked better, while Ritalin was ineffective. Current diagnostic records, target symptoms, dose timing, duration of benefit, rebound, and functional response should be reviewed.

Other Measures No standardized OCD scale documented.

The intake documents moderate obsessions/compulsions and an established OCD diagnosis, but no Y-BOCS or other structured OCD severity measure was included.

Urgent Safety Alerts

Safety Alert Summary

No acute safety emergency is established from the intake. Past thoughts of self-harm were endorsed without attempts, and current PHQ-9 item 9 was negative. Family history includes maternal suicide, increasing the importance of direct current risk assessment.

Trigger Quotes / Source Evidence

Source responses include “Thoughts of killing or harming myself — Past,” “Attempts to kill or harm myself — No,” and PHQ-9 item 9 — “Not at all.” Family history indicates maternal suicide.

Required Risk Follow-Up

Ask directly about current and recent suicidal or homicidal thoughts, self-harm urges, plan, intent, access to lethal means, prior preparatory behavior, triggers, protective factors, supports, and what has changed since the past thoughts occurred.

Intake Summary

Chief Complaint - Verbatim

“OCD and ADHD.”

Chief Complaint - Clinical Framing

Celia is a 47-year-old married woman seeking continued treatment for lifelong OCD and ADHD symptoms that she describes as severe and functionally impairing, particularly because it is difficult for her to work on a task and finish it.

HPI Summary

Celia reports lifelong OCD and ADHD symptoms, formally diagnosed last year, and currently managed with medication. She describes the problem as severe and functionally impairing because she has difficulty working on and completing tasks. Current medications are fluoxetine 60 mg for OCD, Adderall XR 30 mg for ADHD, and levothyroxine 25 mcg for thyroid disease. She reports fluoxetine has helped significantly, Adderall works well but Adzenys XR worked better, and Ritalin was ineffective. The intake also documents moderate obsessions/compulsions, fatigue, mild generalized anxiety, intermittent panic/anxiety attacks, indecisiveness, social isolation, past sleep disturbance, past physical/verbal abuse, past self-harm thoughts without attempts, and grief related to her mother’s death.

AI Voice Briefing

90-Second Provider Briefing Transcript

Briefing Script Celia Smth is a 47-year-old married, unemployed woman presenting for continued treatment of OCD and ADHD. Symptoms are described as lifelong, severe, and impairing task completion. She was diagnosed last year and has received care from Dr. Ronald Moomaw at Salience Health for approximately two years. Current medications are fluoxetine 60 mg, Adderall XR 30 mg, and levothyroxine 25 mcg. She reports fluoxetine is helping, Adderall works well but Adzenys XR was more effective, and Ritalin was ineffective. PHQ-9 is 4 and GAD-7 is 1. Relevant factors include intermittent panic/anxiety attacks, fatigue, past sleep disturbance, migraines, thyroid disease, PCOS, latex allergy, past physical/verbal abuse, past suicidal thoughts without attempts, maternal suicide, and possible maternal bipolar disorder. The first visit should prioritize current safety, OCD severity, ADHD functional response, medication timing and side effects, bipolar-spectrum screening, thyroid status, and treatment continuity.
One-Line Clinical Orientation The central clinical task is to confirm the current diagnostic formulation, characterize residual OCD and ADHD symptoms, assess whether current medications are adequately effective and tolerated, and rule out mood, sleep, medical, or anxiety factors that may affect functioning.

Medication, Psychiatric & Substance History

Current & Prior Medications

Current Regimen

Levothyroxine 25 mcg for thyroid disease; fluoxetine 60 mg for OCD; Adderall XR 30 mg for ADHD. Prescribers, frequency, timing, adherence, refill status, benefit duration, adverse effects, pharmacy, and OTC/supplement use were not documented.

Prior Psychiatric Medication Trials

Past medications include fluoxetine, currently reported as helpful after a little over one year; escitalopram postpartum, reported as not good; Adderall, reported as effective; Adzenys XR, reported as more effective than Adderall; and Ritalin, reported as ineffective. Dates, doses, and reasons for discontinuation are incomplete.

Medication Adherence

Medication adherence, missed doses, early refills, actual timing, duration of effect, rebound, appetite change, sleep impact, cardiovascular effects, activation, emotional blunting, and interactions with thyroid status were not assessed in the available intake.

Psychiatric History

Past Psychiatric History

Diagnosed with OCD and ADHD. She has received mental-health services from Dr. Ronald Moomaw at Salience Health in Frisco, Texas, for approximately two years. No psychotherapy provider was listed, and no psychiatric hospitalization or higher level of care was documented.

Trauma History

Past physical/verbal abuse was endorsed; sexual abuse was denied. Past upsetting memories and thoughts she could not get out of her head were endorsed. Detailed trauma chronology, current trauma symptoms, avoidance, hyperarousal, dissociation, and prior trauma-focused treatment were not assessed.

Psychiatric Hospitalization

Psychiatric hospitalization was not documented; direct confirmation is needed.

Substance Use

Alcohol Use

Reports alcohol use but entered 0 drinks/day, states use over many years, and denied a need to cut down. This response is internally unclear and should be clarified directly, including frequency, amount, last use, binge episodes, consequences, and interaction with medication.

Cannabis Use

Marijuana/cannabis use was not endorsed. Current and lifetime use should be directly confirmed.

Nicotine / Tobacco Use

Nicotine/cigarette use was not endorsed. Vaping, smokeless tobacco, prior use, and quit history were not specifically assessed.

Other Substance Use

Prescription amphetamine use was endorsed and is consistent with Adderall XR treatment. Other listed substances were not endorsed. Clarify nonmedical use, diversion, caffeine/energy products, sedatives, opioids, and all other substances.

Mandatory Intake Questions

1

Immediate Safety & Stability

Have you had any recent thoughts of wanting to die, harming yourself, harming someone else, or feeling unable to stay safe, and do you have access to firearms or other lethal means?

2

Symptom Timeline & Functional Impact

Please describe the current OCD symptoms and ADHD symptoms separately, including how often they occur, what triggers them, and how they interfere with task completion, home responsibilities, relationships, and sleep.

3

Mood, Activation & Bipolar Screen

Have you ever had a distinct period of several days with unusually elevated or irritable mood, markedly reduced need for sleep, increased energy, rapid speech or thoughts, unusual confidence, impulsive behavior, or a clear change from your usual self?

4

Medication History & Adherence

How are you taking fluoxetine, Adderall XR, and levothyroxine; who prescribes each medication; how long does each dose help; and what side effects, rebound symptoms, or missed-dose effects have you noticed?

5

Substance, Sleep & Medical Contributors

Please describe your current sleep schedule, stimulant timing, caffeine use, migraine pattern, thyroid follow-up, PCOS symptoms, and whether fatigue changes with medication or medical status.

6

Goals, Supports & Readiness

Of OCD symptoms, task completion, attention, panic/anxiety attacks, fatigue, and treatment continuity, which concern matters most right now, and what would meaningful improvement look like over the next three months?

First-Session Priorities

1. Opening Focus

Use a validating transfer-of-care approach: “You have already done meaningful treatment work and learned which medications help. I want to understand what is still getting in the way and what you want to improve next.”

2. Essential Clarifications

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

3. Engagement Strategy

Use a validating transfer-of-care approach: “You have already done meaningful treatment work and learned which medications help. I want to understand what is still getting in the way and what you want to improve next.”

4. Avoid Over-Assuming

Past physical/verbal abuse was endorsed; sexual abuse was denied. Past upsetting memories and intrusive upsetting thoughts were reported. Clarify chronology, current trauma symptoms, avoidance, hyperarousal, dissociation, interpersonal safety, and prior treatment.

First-Visit Agenda

Provider-facing visit structure generated from the available intake materials. Use this as a flexible agenda, not a substitute for clinical judgment.

1. Opening & Orientation

Clinical task

Review goals and confidentiality; confirm safety; characterize current OCD and ADHD symptoms; assess medication response and side effects; review panic, worry, sleep, grief, trauma, and bipolar-spectrum symptoms; reconcile medical history; and agree on next steps.

Suggested wording

Use a validating transfer-of-care approach: “You have already done meaningful treatment work and learned which medications help. I want to understand what is still getting in the way and what you want to improve next.”

2. Safety Screen

Clinical task

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Suggested wording

Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.

3. Symptom Timeline

Clinical task

Current difficulty falling or staying asleep was denied, while past sleeping too little or too much and general sleep concerns were endorsed. Clarify current schedule, duration, quality, snoring, apnea symptoms, stimulant timing, naps, caffeine, and daytime fatigue.

Suggested wording

Clarify lifelong onset, diagnostic evaluation last year, two years of prior psychiatric care, medication sequence and response, current residual symptoms, recent changes, and specific functional impairment.

4. Diagnostic Screening

Clinical task

Past physical/verbal abuse was endorsed; sexual abuse was denied. Past upsetting memories and intrusive upsetting thoughts were reported. Clarify chronology, current trauma symptoms, avoidance, hyperarousal, dissociation, interpersonal safety, and prior treatment.

What to listen for

“Can you give a recent example, explain what happened before the task stalled, what thoughts or urges showed up, what you did next, and how medication timing affected the outcome?”

5. Medication & Medical Review

Clinical task

Physical health was rated good. Medical history includes thyroid disease, headaches/migraines, and PCOS. Chronic pain was denied. Latex allergy causes hives. PCP, pharmacy, vitals, height, weight, BMI, recent thyroid studies, migraine treatment, and PCOS management were not documented.

Clarification question

“Can you give a recent example, explain what happened before the task stalled, what thoughts or urges showed up, what you did next, and how medication timing affected the outcome?”

6. Treatment Plan & Next Steps

Clinical task

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Closing question

“What would feel like the most meaningful improvement over the next few months, and what concerns do you have about changing anything that is currently helping?”

Diagnostic Decision Support, Measurement-Based Care & Intake Interventions

Working differential, targeted measurement, focused intake questions, provider language, and immediate first-visit interventions.

QuestionWhy It MattersWhat to Listen For
What OCD symptoms are currently present, what ADHD symptoms remain despite medication, and which specific symptoms are causing the greatest functional impairment now? The answer helps distinguish residual symptoms of established disorders from side effects, comorbid conditions, or medical contributors, and therefore changes whether the next step should be medication optimization, psychotherapy, medical coordination, or additional diagnostic workup. Listen for intrusive thoughts, compulsions, avoidance, reassurance seeking, task-initiation failure, distractibility, duration of stimulant benefit, rebound, chronic versus episodic symptoms, sleep change, thyroid-related fatigue, panic triggers, protective factors, and evidence of functional improvement or deterioration.
Are panic, worry, irritability, and fatigue secondary to OCD and ADHD burden, medication effects, sleep, thyroid dysfunction, grief, trauma, or a separate anxiety or mood condition? The answer helps distinguish residual symptoms of established disorders from side effects, comorbid conditions, or medical contributors, and therefore changes whether the next step should be medication optimization, psychotherapy, medical coordination, or additional diagnostic workup. Listen for intrusive thoughts, compulsions, avoidance, reassurance seeking, task-initiation failure, distractibility, duration of stimulant benefit, rebound, chronic versus episodic symptoms, sleep change, thyroid-related fatigue, panic triggers, protective factors, and evidence of functional improvement or deterioration.
Has there ever been a distinct period of elevated or irritable mood, decreased need for sleep, increased energy, rapid speech or thoughts, or impulsive behavior that would support bipolar-spectrum concern? The answer helps distinguish residual symptoms of established disorders from side effects, comorbid conditions, or medical contributors, and therefore changes whether the next step should be medication optimization, psychotherapy, medical coordination, or additional diagnostic workup. Listen for intrusive thoughts, compulsions, avoidance, reassurance seeking, task-initiation failure, distractibility, duration of stimulant benefit, rebound, chronic versus episodic symptoms, sleep change, thyroid-related fatigue, panic triggers, protective factors, and evidence of functional improvement or deterioration.

Measurement-Based Care

Recommended Scales / Tracking

Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or equivalent structured OCD severity measureAdminister during the intake or early follow-up to establish current severity, quantify treatment response, identify safety concerns, and determine whether medication optimization, psychotherapy, or additional diagnostic clarification is needed.
Adult ADHD rating scale or structured ADHD follow-up assessment focused on current treatment responseAdminister during the intake or early follow-up to establish current severity, quantify treatment response, identify safety concerns, and determine whether medication optimization, psychotherapy, or additional diagnostic clarification is needed.
Columbia-Suicide Severity Rating Scale (C-SSRS) or equivalent structured risk assessmentAdminister during the intake or early follow-up to establish current severity, quantify treatment response, identify safety concerns, and determine whether medication optimization, psychotherapy, or additional diagnostic clarification is needed.

Targeted Intake Interventions & Provider Scripts

Provider Scripts

1.Not documented in the available intake; clarify directly during the initial evaluation.Note: This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.
2.Not documented in the available intake; clarify directly during the initial evaluation.Note: This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.
3.Not documented in the available intake; clarify directly during the initial evaluation.Note: This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.
4.Not documented in the available intake; clarify directly during the initial evaluation.Note: Not documented in the available intake; clarify directly during the initial evaluation.
5.Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.Note: Consider Exposure and Response Prevention for OCD, CBT-informed executive-function support, panic-management skills, grief-informed therapy if indicated, trauma-informed assessment, behavioral activation around daily structure, and family or partner education when helpful.
6.Consider Exposure and Response Prevention for OCD, CBT-informed executive-function support, panic-management skills, grief-informed therapy if indicated, trauma-informed assessment, behavioral activation around daily structure, and family or partner education when helpful.Note: This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.

Provider Review Priorities

Provider-facing items to confirm early in the visit.
1. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
2. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
3. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
4. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
5. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
6. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.
7. Not documented in the available intake; clarify directly during the initial evaluation.Not documented in the available intake; clarify directly during the initial evaluation.

Recommended Differentials & Clinical Blindspots / Red Flags

Recommended Differentials

Present up to four clinically supported differentials in a two-column layout. Keep each diagnosis in its own block and distinguish documented evidence from hypotheses requiring provider review.

Likely historical diagnoses include OCD and ADHD; exact DSM-5-TR and ICD-10 coding should be confirmed from prior records and direct assessment.Supporting findings include the patient’s reported OCD and ADHD diagnoses, two years of specialty psychiatric care, current fluoxetine 60 mg and Adderall XR 30 mg, moderate obsessions/compulsions on the symptom checklist, severe task-completion impairment by report, and medication-specific response history.
Likely historical diagnoses include OCD and ADHD; exact DSM-5-TR and ICD-10 coding should be confirmed from prior records and direct assessment.Supporting findings include the patient’s reported OCD and ADHD diagnoses, two years of specialty psychiatric care, current fluoxetine 60 mg and Adderall XR 30 mg, moderate obsessions/compulsions on the symptom checklist, severe task-completion impairment by report, and medication-specific response history.
Likely historical diagnoses include OCD and ADHD; exact DSM-5-TR and ICD-10 coding should be confirmed from prior records and direct assessment.Supporting findings include the patient’s reported OCD and ADHD diagnoses, two years of specialty psychiatric care, current fluoxetine 60 mg and Adderall XR 30 mg, moderate obsessions/compulsions on the symptom checklist, severe task-completion impairment by report, and medication-specific response history.
Likely historical diagnoses include OCD and ADHD; exact DSM-5-TR and ICD-10 coding should be confirmed from prior records and direct assessment.Supporting findings include the patient’s reported OCD and ADHD diagnoses, two years of specialty psychiatric care, current fluoxetine 60 mg and Adderall XR 30 mg, moderate obsessions/compulsions on the symptom checklist, severe task-completion impairment by report, and medication-specific response history.

Clinical Blindspots and Red Flags

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

Not documented in the available intake; clarify directly during the initial evaluation.

This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.

Action: Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

Not documented in the available intake; clarify directly during the initial evaluation.

This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.

Action: Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

Not documented in the available intake; clarify directly during the initial evaluation.

This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.

Action: Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

Do not assume that low PHQ-9 and GAD-7 scores mean no clinically meaningful anxiety or risk. The intake documents intermittent panic attacks, constant worry, past suicidal thoughts, maternal suicide, and severe self-reported impairment. Also avoid changing established treatment without confirming prior records and current response.

This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.

Action: Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.

Medical, Physiological, Social & Family Context

Medical / Vitals / Labs

Medical History

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Vitals and Baseline Labs

Physical health was rated good. Medical history includes thyroid disease, headaches/migraines, and PCOS. Chronic pain was denied. Latex allergy causes hives. PCP, pharmacy, vitals, height, weight, BMI, recent thyroid studies, migraine treatment, and PCOS management were not documented.

Medical Rule-Outs / Physiological Considerations

Physical health was rated good. Medical history includes thyroid disease, headaches/migraines, and PCOS. Chronic pain was denied. Latex allergy causes hives. PCP, pharmacy, vitals, height, weight, BMI, recent thyroid studies, migraine treatment, and PCOS management were not documented.

Allergies and Safety Factors

Allergies

Not documented in the available intake; clarify directly during the initial evaluation.

Side Effects / Medication Risks

Review stimulant effects on sleep, anxiety, appetite, pulse, and blood pressure; fluoxetine activation and interaction considerations; thyroid status and levothyroxine timing; migraine pattern; and any OTC or supplement use. No specific interaction should be assumed without complete reconciliation.

Substance-Related Medication Risk

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Social and Family Context

Living Situation

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Relationship / Family Context

Available findings have been synthesized above; unresolved questions should be addressed through direct interview, structured symptom measurement, medication reconciliation, prior-record review, and patient-defined goals.

Occupational / Educational Functioning

Available findings have been synthesized above; unresolved questions should be addressed through direct interview, structured symptom measurement, medication reconciliation, prior-record review, and patient-defined goals.

Family Psychiatric History

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Risk, Safety Review & Crisis Plan

Suicidal Ideation

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Self-Harm / NSSI

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Homicidal Ideation

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Psychosis / Mania / Intoxication

Do not abruptly stop fluoxetine, Adderall XR, levothyroxine, or other prescribed medication without coordinated clinical review. Any change should be individualized and documented.

Protective Factors

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Safety Plan / Crisis Instructions

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Individualized Crisis-Planning Details

Warning SignsAvailable findings have been synthesized above; unresolved questions should be addressed through direct interview, structured symptom measurement, medication reconciliation, prior-record review, and patient-defined goals.
Internal CopingAvailable findings have been synthesized above; unresolved questions should be addressed through direct interview, structured symptom measurement, medication reconciliation, prior-record review, and patient-defined goals.
Social / Professional SupportsUnemployed, married for 10 years, and living in adequate housing. Husband William Smith is the emergency contact. Education, prior occupation, financial context, caregiving responsibilities, relationship functioning, and current daily structure were not fully assessed.

Care Planning Handoff & Preliminary Treatment Plan

Initial care direction, records and collateral, post-visit setup, and a coordinated multimodal treatment framework for provider review.

Likely Care Needs

Initial Care Direction

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Records / Collateral

Recommended Records to Request

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

After-Visit Setup

Likely Post-Intake Tasks

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Preliminary Multimodal Treatment Plan

Multimodal Plan

Not documented in the available intake; clarify directly during the initial evaluation.This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.
Not documented in the available intake; clarify directly during the initial evaluation.Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.
Not documented in the available intake; clarify directly during the initial evaluation.This clarification is needed to separate residual symptoms of established diagnoses from side effects, comorbid conditions, or medical contributors and to choose the safest and most efficient treatment sequence.
Not documented in the available intake; clarify directly during the initial evaluation.Administer during the intake or early follow-up to establish current severity, quantify treatment response, identify safety concerns, and determine whether medication optimization, psychotherapy, or additional diagnostic clarification is needed.

Clinical Tools and Provider Support

Medication / Physiological Risks

Risk Review

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Drug Interactions

Review stimulant effects on sleep, anxiety, appetite, pulse, and blood pressure; fluoxetine activation and interaction considerations; thyroid status and levothyroxine timing; migraine pattern; and any OTC or supplement use. No specific interaction should be assumed without complete reconciliation.

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Pharmacotherapy Ideas

Patient-Specific Medication Options for Provider Review

Continue current medications provisionally while confirming adherence, benefit, adverse effects, blood pressure, pulse, sleep, thyroid status, and continuity with prior records.

Clinical rationale: Levothyroxine 25 mcg for thyroid disease, fluoxetine 60 mg for OCD, and Adderall XR 30 mg for ADHD. Confirm dose timing, formulation, prescribers, pharmacy, adherence, benefit, adverse effects, refill history, and all OTC products or supplements.

Before considering: Review stimulant effects on sleep, anxiety, appetite, pulse, and blood pressure; fluoxetine activation and interaction considerations; thyroid status and levothyroxine timing; migraine pattern; and any OTC or supplement use. No specific interaction should be assumed without complete reconciliation.

Monitoring: Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

If residual ADHD symptoms remain despite adherence, consider whether formulation or duration of stimulant coverage should be adjusted after reviewing prior Adzenys XR response, cardiovascular status, sleep, and misuse/diversion risk.

Clinical rationale: Available findings have been synthesized above; unresolved questions should be addressed through direct interview, structured symptom measurement, medication reconciliation, prior-record review, and patient-defined goals.

Risks / cautions: Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Monitoring: Not documented in the available intake; clarify directly during the initial evaluation.

If clinically significant OCD symptoms remain despite fluoxetine 60 mg, consider evidence-based OCD treatment optimization, including ERP-focused psychotherapy and medication strategy review, after confirming adherence, duration, response, side effects, and prior treatment.

Clinical rationale: Do not abruptly stop fluoxetine, Adderall XR, levothyroxine, or other prescribed medication without coordinated clinical review. Any change should be individualized and documented.

Safeguards: Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Medication Decision Summary

Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment.

Client-Facing Materials

Content in this section is intended for patient-facing communication or education and should remain at the bottom of the template.

Empathetic Patient Summary Letter

Subject

Welcome to Integrative Psychiatry — Preparing for Your Intake Visit

Letter Body

Dear Celia,

Thank you for completing your intake materials. You described longstanding OCD and ADHD symptoms that continue to interfere with starting and finishing tasks despite meaningful benefit from medication. Your experience and prior treatment history will be reviewed carefully.

During the visit, we will separate current OCD symptoms from attention and executive-function symptoms, review what each medication is helping, and assess whether anxiety, sleep, thyroid health, migraines, grief, or past trauma are affecting your day-to-day functioning.

Because you reported past thoughts of harming yourself and a family history of suicide, the visit will include direct, supportive safety questions. This is a routine part of making sure the treatment plan is appropriate and that useful supports are in place.

Please bring an updated medication list, pharmacy information, recent thyroid or other medical results if available, and records from your prior psychiatric care when possible. Your priorities and preferences will guide the next steps.

Client-Facing Psychoeducation

Understanding OCD and ADHD as Different but Overlapping ConditionsOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
How Anxiety, Grief, Sleep, and Medical Factors Can Affect FocusOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Separating Symptoms from Shame or Self-BlameOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Sleep, Energy, and Daily RhythmOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Medication Safety and Response TrackingOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Communication and Task Completion at HomeOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Practical Executive-Function and OCD Coping StrategiesOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
What Collaborative Treatment Can Look LikeOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.
Tracking Progress and Knowing When to Seek More HelpOCD and ADHD can both make tasks feel difficult, but for different reasons. ADHD may make it hard to start, organize, remember, or stay with a task. OCD may create intrusive thoughts, doubt, checking, or a need to do things in a certain way before moving forward. Tracking what happens just before a task stalls can help identify which process is active. Use one calendar and one task list, break work into very small next steps, limit reassurance or checking when it is part of OCD, and note medication timing, sleep, and energy. Seek urgent help for new suicidal thoughts, inability to stay safe, or a marked change in mood or behavior.

Missing / Not Documented Clinical Data Checklist

Provider-facing checklist placed at the bottom by request. Use this to verify what still needs to be clarified before finalizing diagnosis, risk formulation, or treatment planning.

Clinical Domain Missing / Not Documented Items to Flag Provider Follow-Up
Vitals / Medical Baseline Physical health was rated good. Medical history includes thyroid disease, headaches/migraines, and PCOS. Chronic pain was denied. Latex allergy causes hives. PCP, pharmacy, vitals, height, weight, BMI, recent thyroid studies, migraine treatment, and PCOS management were not documented. Not documented in the available intake; clarify directly during the initial evaluation.
Medication Data Levothyroxine 25 mcg for thyroid disease, fluoxetine 60 mg for OCD, and Adderall XR 30 mg for ADHD. Confirm dose timing, formulation, prescribers, pharmacy, adherence, benefit, adverse effects, refill history, and all OTC products or supplements. Not documented in the available intake; clarify directly during the initial evaluation.
Risk / Safety Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment. Ask directly and nonjudgmentally about current and recent SI, HI, self-harm urges, plan, intent, means access, prior preparatory behavior, alcohol or medication involvement, protective factors, supports, and crisis resources.
Diagnostic Screens Current difficulty falling or staying asleep was denied, while past sleeping too little or too much and general sleep concerns were endorsed. Clarify current schedule, duration, quality, snoring, apnea symptoms, stimulant timing, naps, caffeine, and daytime fatigue. “Can you give a recent example, explain what happened before the task stalled, what thoughts or urges showed up, what you did next, and how medication timing affected the outcome?”
Substance Use Do not abruptly stop fluoxetine, Adderall XR, levothyroxine, or other prescribed medication without coordinated clinical review. Any change should be individualized and documented. Prescription amphetamine use was endorsed and is consistent with Adderall XR treatment. Confirm prescribed use, adherence, misuse or diversion, caffeine and energy products, and any unreported sedative, opioid, or other substance use.
Psychiatric / Trauma History Past suicidal or self-harm thoughts were endorsed without attempts; current PHQ-9 item 9 was negative. Family history includes maternal suicide. Current intent, plan, means access, HI, protective factors, and crisis supports require direct assessment. Past physical/verbal abuse was endorsed; sexual abuse was denied. Past upsetting memories and intrusive upsetting thoughts were reported. Clarify chronology, current trauma symptoms, avoidance, hyperarousal, dissociation, interpersonal safety, and prior treatment.
Social / Functional Context Unemployed, married for 10 years, and living in adequate housing. Husband William Smith is the emergency contact. Education, prior occupation, financial context, caregiving responsibilities, relationship functioning, and current daily structure were not fully assessed. Unemployed, married for 10 years, and living in adequate housing. Husband William Smith is the emergency contact. Education, prior occupation, financial context, caregiving responsibilities, relationship functioning, and current daily structure were not fully assessed.
Records / ROI / Collateral Physical health was rated good. Medical history includes thyroid disease, headaches/migraines, and PCOS. Chronic pain was denied. Latex allergy causes hives. PCP, pharmacy, vitals, height, weight, BMI, recent thyroid studies, migraine treatment, and PCOS management were not documented. With authorization, obtain records from Dr. Ronald Moomaw and Salience Health, pharmacy history, PCP and thyroid records, and consider spouse collateral regarding current functional impairment and medication response.
Global Missing Fields Missing or incomplete: middle initial, exact spelling of last name, education, prior occupation, PCP, pharmacy, vitals, height/weight/BMI, medication prescribers and timing, adherence and side effects, exact OCD symptom dimensions, current ADHD symptom count, prior diagnostic testing, psychotherapy history, psychiatric hospitalization history, current SI/HI details, means access, protective factors, full alcohol pattern, caffeine and complete substance history, current sleep schedule, trauma details, thyroid labs, migraine treatment, PCOS management, and prior records. Before finalizing the intake: confirm current safety; clarify OCD and ADHD symptom burden separately; review fluoxetine and stimulant response; assess bipolar-spectrum risk given family history; review panic, sleep, thyroid and migraine factors; verify medication records; and align the plan with the patient’s goal of continued growth.