Psychiatric Evaluation & Assessment
What to Expect at Your First Visit
Your first appointment at RECO Integrated Psychiatry is a comprehensive psychiatric evaluation, a thorough, unhurried assessment designed to give your psychiatrist a complete picture of your mental health. Unlike a brief medication check, our initial evaluations are typically 60 to 90 minutes in length, allowing ample time to explore your symptoms, history, and goals in depth.
We understand that seeking psychiatric care for the first time, or starting with a new provider, can feel daunting. Our team is committed to creating a welcoming, non-judgmental, and confidential environment where you can speak openly about your experiences. Everything you share during your evaluation is protected by HIPAA and the ethical obligations of doctor-patient confidentiality.
Before You Arrive
To make the most of your evaluation appointment, we recommend preparing the following before your visit:
- Completed intake forms: We will send you digital intake paperwork to complete before your appointment. This includes demographic information, medical history, symptom questionnaires, and consent forms.
- Medication list: Bring a complete list of all medications, vitamins, and supplements you are currently taking, including dosages and how long you have been taking each one.
- Previous records: If available, bring any prior psychiatric or psychological evaluations, test results, hospital discharge summaries, or treatment records from previous providers.
- Insurance information: Bring your insurance card and a valid photo ID. If you have questions about coverage, contact our admissions team at (561) 464-4077 or visit our insurance verification page.
- Questions and concerns: Write down any questions you want to ask or specific concerns you want to address during your appointment.
During the Evaluation
Your psychiatrist will guide you through a structured but conversational clinical interview covering multiple domains of your mental health and overall well-being. The evaluation is not a test, and there are no right or wrong answers. Your honest and open communication helps your psychiatrist build the most accurate understanding of your situation.
The Comprehensive Assessment Process
Our psychiatric evaluation follows a systematic approach designed to capture the full complexity of your mental health. Each component of the assessment provides important information that contributes to an accurate diagnosis and effective treatment plan.
Chief Complaint and Present Illness
Your psychiatrist begins by asking what brings you in today. This open-ended discussion explores your current symptoms, their severity, duration, triggers, and impact on your daily functioning, relationships, and quality of life. Understanding the timeline and evolution of your symptoms is essential for accurate diagnosis.
Psychiatric History
A detailed review of your past psychiatric history, including previous diagnoses, hospitalizations, medication trials (what worked, what did not, what caused side effects), therapy experiences, and any history of self-harm or suicidal ideation. This information helps identify patterns and informs treatment decisions.
Medical History and Review of Systems
Because many medical conditions can present with psychiatric symptoms or complicate psychiatric treatment, your psychiatrist reviews your medical history, including chronic conditions, surgeries, allergies, and current medications. A brief review of organ systems screens for medical issues that may be contributing to your symptoms.
Social and Developmental History
Understanding your life context is crucial. This portion covers your upbringing, education, employment, relationships, living situation, social support network, and any significant life events or traumas. Cultural background and personal values are also explored to ensure culturally sensitive treatment.
Family Psychiatric History
Mental health conditions often run in families. Understanding your family's psychiatric history, including conditions like depression, bipolar disorder, anxiety, substance use disorders, and suicide, helps your psychiatrist identify potential genetic predispositions and informs treatment selection.
Substance Use Assessment
An honest and non-judgmental assessment of your use of alcohol, nicotine, cannabis, prescription medications, and other substances. Substance use can significantly affect psychiatric symptoms and medication management, making accurate assessment essential for safe and effective treatment planning.
Mental Status Examination
The mental status examination (MSE) is a systematic clinical assessment of your cognitive and emotional functioning at the time of the interview. Your psychiatrist observes and evaluates your appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. The MSE provides an objective snapshot that complements the subjective information gathered during the interview.
Diagnostic Tools and Assessment Instruments
In addition to the clinical interview and mental status examination, your psychiatrist may utilize standardized assessment instruments to gather additional data and support diagnostic accuracy.
Standardized Rating Scales
Validated self-report and clinician-administered scales provide quantitative measures of symptom severity for specific conditions. Common instruments used at RECO Integrated Psychiatry include:
- PHQ-9 (Patient Health Questionnaire-9): A widely used screening and severity measure for depression
- GAD-7 (Generalized Anxiety Disorder-7): Measures the severity of generalized anxiety symptoms
- PCL-5 (PTSD Checklist for DSM-5): Assesses symptoms of post-traumatic stress disorder
- Y-BOCS (Yale-Brown Obsessive Compulsive Scale): Evaluates the severity of OCD symptoms
- MDQ (Mood Disorder Questionnaire): Screens for bipolar spectrum disorders
- ASRS (Adult ADHD Self-Report Scale): Screens for attention-deficit/hyperactivity disorder in adults
- Columbia Suicide Severity Rating Scale (C-SSRS): Assesses suicidal ideation and behavior
Pharmacogenomic Testing
When medication is being considered as part of your treatment plan, your psychiatrist may recommend pharmacogenomic testing (a simple cheek swab) to analyze how your genes affect your response to specific psychiatric medications. The results help guide medication selection and dosing, reducing trial-and-error and improving the likelihood of finding the right medication faster.
Laboratory Testing
Your psychiatrist may order blood tests to rule out medical conditions that can mimic or contribute to psychiatric symptoms. Common lab tests include thyroid function panel, complete blood count, comprehensive metabolic panel, vitamin D and B12 levels, and toxicology screening when clinically indicated.
Treatment Planning: Your Personalized Roadmap
At the conclusion of your evaluation, your psychiatrist will discuss their initial diagnostic impressions and work collaboratively with you to develop a personalized treatment plan. This plan serves as a roadmap for your care and may include any combination of the following:
- Medication management: If medication is recommended, your psychiatrist will explain the rationale, expected benefits, potential side effects, and timeline for each recommended medication.
- Psychotherapy referrals: If therapy is indicated, your psychiatrist will recommend specific modalities (such as CBT, DBT, EMDR, or psychodynamic therapy) and can coordinate with our therapy team or your existing therapist.
- Advanced treatments: For conditions that may benefit from TMS therapy, Spravato, or IV ketamine, your psychiatrist will discuss candidacy, expected outcomes, and next steps.
- Program recommendations: For patients who may benefit from a more intensive level of care, referrals to our outpatient, IOP, or PHP programs may be provided.
- Lifestyle modifications: Evidence-based recommendations for sleep hygiene, exercise, nutrition, stress management, and social engagement that complement your medical treatment.
- Follow-up schedule: A clear plan for follow-up appointments to monitor your response, adjust treatment, and track your progress over time.
Same-Week Appointments Available
At RECO Integrated Psychiatry, we understand that waiting weeks for an initial psychiatric evaluation can feel overwhelming when you are struggling. We offer same-week appointments to help you begin your journey toward wellness as soon as possible. Call (561) 464-4077 or schedule online to book your evaluation.
Frequently Asked Questions
A comprehensive psychiatric evaluation at RECO Integrated Psychiatry typically lasts 60 to 90 minutes. This is significantly longer than the 15 to 20-minute appointments common at many practices, because we believe thorough assessment is the foundation for effective treatment. Complex cases may require additional time or a follow-up appointment to complete the evaluation. Please plan to arrive 15 minutes early to complete any remaining paperwork.
Please bring a valid photo ID, your insurance card, a complete list of current medications and supplements (including dosages), any previous psychiatric or psychological records you may have, and a list of questions or concerns you would like to discuss. If you have completed any intake forms we sent in advance, please ensure they are finished before your arrival. Bringing a trusted family member or friend who can provide additional perspective on your symptoms is also welcome, with your permission.
In most cases, you do not need a referral to schedule a psychiatric evaluation at RECO Integrated Psychiatry. You can self-refer by contacting our office directly. However, some insurance plans (particularly HMO plans) may require a referral from your primary care physician for psychiatric services. Our admissions team can verify your specific insurance requirements and help you obtain any necessary referrals. Call (561) 464-4077 for assistance.
Absolutely. All information shared during your psychiatric evaluation is protected by federal HIPAA regulations and the ethical standards of doctor-patient confidentiality. Your records will not be shared with any outside party without your explicit written consent. The limited exceptions, which your psychiatrist will explain, include situations involving imminent danger to yourself or others, suspected child or elder abuse, or court orders. Our commitment to your privacy is fundamental to the therapeutic relationship.
In many cases, yes. Your psychiatrist will typically provide a working diagnosis and discuss their clinical impressions with you at the end of the initial evaluation. However, psychiatric diagnosis requires careful consideration, and some presentations may require additional information gathering, psychological testing, or observation over time before a definitive diagnosis can be established. A working diagnosis is sufficient to begin treatment, and it can be refined as more information becomes available. Your psychiatrist will always be transparent about their diagnostic reasoning.
Yes. Every initial evaluation at RECO Integrated Psychiatry concludes with a discussion of treatment recommendations. You will leave your first visit with a clear understanding of your diagnosis (or working diagnosis), recommended treatments, next steps, and a follow-up schedule. If medication is recommended, your psychiatrist will discuss the options, provide prescriptions if appropriate, and schedule a follow-up within two to four weeks to assess your response. Our goal is for every patient to leave their first visit feeling informed, empowered, and hopeful.