Initial Psychiatric Interview/SOAP Note Template Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: Susan DOB: not provided Minor: NA Accompanied by: self Demographic: NA Gender Identifier Note: Female CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days” . HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn't realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks. Pertinent history in record and from patient: Alcohol withdrawal During assessment: Patient is cam and corparative Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells. Patient denies hallucinating. The patient has nomal thought process. . SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none reported History of Violence t o Others: none reported Auditory Hallucinations: not reported Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Priorsubstance abuse treatment: not reported Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure .