Connect and orient
Introduce your role, confirm who is present, explain the purpose and limits of the encounter, and establish psychological and physical comfort.
BH
Brooke Harbor Health System
PMHNP Clinical Learning Environment
Assessment Resource
Clinical Workflow ToolPoint-of-care support for a defined clinical task.
Psychiatric Interview & History
The psychiatric interview is both a clinical assessment and a therapeutic encounter. Use a flexible structure to understand the patient's experience, gather essential evidence, assess safety, and begin a collaborative working relationship.
Clinical application
Using this resource
Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.
Use this when
- An initial or follow-up encounter requires a clinically focused understanding of the person’s concern, course, context, function, and priorities.
Clarify first
- Confirm the encounter’s purpose, who is present, the available sources, and whether safety, medical status, or capacity requires immediate attention.
Act now
- Begin with the person’s account, then use focused follow-up to establish the timeline and relevant psychiatric, medical, substance, risk, functional, cultural, and contextual history.
- Seek collateral when appropriate and distinguish what was reported, observed, elicited, corroborated, and remains unknown.
Document and communicate
- Preserve the person’s meaning and chronology while recording sources, pertinent findings, function, context, risk, uncertainty, and the next clinical questions.
Escalate or consult when
- The interview identifies an immediate safety concern, possible medical instability, or another need that cannot be safely addressed within the current encounter or setting.
Invite the patient’s story
Begin broadly. Ask what brought the patient in now, what feels most important, and what they hope will be different after the visit.
Clarify and organize
Develop the timeline, severity, functional effect, context, associated features, and relevant negatives without turning the conversation into a checklist.
Complete the clinical picture
Explore psychiatric, medical, developmental, family, social, cultural, trauma, substance, treatment, and medication history.
Synthesize and close
Summarize what you heard, check accuracy, address urgent concerns, invite questions, and explain what will happen next.
Core history
Build a whole-person clinical picture
Depth depends on the setting, urgency, developmental stage, patient capacity, and purpose of the encounter. Verify previously documented information rather than assuming it remains accurate.
Presenting concern and goals
Why now? What changed? Whose concern is it? What does the patient want help with?
History of present illness
Onset, course, triggers, severity, associated symptoms, prior episodes, function, coping, and relevant negatives.
Psychiatric history
Prior diagnoses, treatment settings, hospitalizations, crises, self-harm, violence, psychotherapy, and response to care.
Medication history
Current and prior medications, adherence, benefit, adverse effects, reasons stopped, access, and nonprescribed use.
Substance and caffeine use
Substance, amount, frequency, pattern, last use, consequences, tolerance, withdrawal, recovery efforts, and readiness for change.
Medical and neurologic history
Conditions, pain, sleep, reproductive factors, head injury, seizures, procedures, allergies, and possible medical contributors.
Family history
Psychiatric conditions, substance use, suicide, treatment response, medical conditions, relationships, and family understanding of symptoms.
Developmental and social history
Pregnancy and birth when relevant, milestones, education, work, relationships, living situation, legal history, military service, and supports.
Trauma and adverse experiences
Ask with permission, explain relevance, avoid unnecessary detail, assess current impact, and support choice and control.
Culture, identity, and context
Language, identity, beliefs, community, discrimination, spirituality, explanatory model, social conditions, and barriers to care.
From story to evidence
Move from open exploration to focused clarification
Broad questions reveal the patient's priorities and language. Focused questions then establish clinical detail, distinguish among explanations, and identify what requires action.
“Tell me what the last few weeks have been like for you.”
“When did you first notice a change? What was happening around then?”
“When you say anxious, what does that feel like in your body and thoughts?”
“How has this affected sleep, school or work, relationships, and daily responsibilities?”
Ask focused questions about associated symptoms, medical contributors, medications, substances, and relevant diagnostic exclusions.
“What do you think is happening, and what worries you most about it?”
Interview techniques
Keep the encounter clinically focused and human
- Open questions, reflection, clarification, and summaries
- Plain, neutral, nonstigmatizing language
- Permission before sensitive or trauma-related questions
- Specific behavioral examples instead of labels alone
- Silence and pacing that allow the patient to think
- Direct, calm questions about suicide, violence, and safety
- Rapid-fire questioning or abrupt topic changes
- Leading questions that imply the preferred answer
- Premature reassurance, interpretation, or diagnosis
- Jargon, stacked questions, and vague timeframes
- Accepting copied history without patient verification
- Avoiding difficult questions because they feel uncomfortable
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A Note on Integrated Care
Consider the body, environment, and psychiatric presentation together
Ask how physical health, medications, sleep, nutrition, pain, hormones, substances, cognition, trauma, culture, relationships, work, finances, housing, and access to care may contribute to the presentation or shape a realistic plan.
Structured cultural assessment
Use a standardized format when culture and context shape the diagnosis
The Cultural Formulation Interview is a semistructured DSM-5-TR interview of sixteen questions across four domains: how the person defines the problem, their understanding of its cause, context and supports, factors affecting self-coping and past help-seeking, and factors affecting help-seeking now. It is intended for use with every patient rather than only when there is obvious cultural difference between patient and clinician, and it supports clinical decision-making rather than establishing a diagnosis on its own. APA permits clinicians to reproduce it for use with their own patients, but it may not be modified without written permission.
Cultural Formulation Interview
The core sixteen-question interview, with instructions to the interviewer.
Open the CFI ↗CFI Informant Version
Parallel interview for a family member or other informant, useful when collateral shapes the picture.
Open the informant version ↗DSM-5-TR Online Assessment Measures
Hosts the alternative CFI versions and the twelve supplementary modules covering areas such as explanatory models, migration, spirituality, and older adults.
Open the measures library ↗Last updated July 29, 2026