What is the process for getting a mental health diagnosis? It starts with a conversation.

Your first visit is often called an intake or evaluation.

During this visit, a mental health clinician will ask questions about how you have been feeling and what has been happening in your life. They are not looking for “right” or “wrong” answers. They are trying to understand the full picture.

An evaluation goes over questions about your thoughts, feelings, behavior, health history, and daily life. A clinician may also recommend a physical exam, lab work, or other testing if there is a chance that a medical condition could be causing some of the symptoms.

For older adults, this step can be especially helpful. Some medicines and health conditions can cause changes in mood, memory, sleep, or thinking and often can resolve quickly when addressed properly.

What will your clinician ask about

Every evaluation is a little different.

Your clinician may ask about:

• What has been bothering you
• When you first noticed the changes
• How often the symptoms happen
• Your mood, sleep, energy, memory, or appetite
• Your medical history
• Medicines you take
• Alcohol or other substance use
• Stress or major changes in your life
• Past mental health care
• How the symptoms affect your daily life
• Who form your social support

They may also ask about your family health history.

If you are comfortable, a caregiver or family member can also be part of this appointment to share what they have noticed. A psychiatric evaluation can include information from family when it helps the clinician understand what has been happening.

You do not need to remember everything on the spot. Bringing notes is okay.

Who can provide a mental health evaluation?

Different types of licensed mental health professionals can take part in an evaluation.

These may include:

Psychiatrists: Doctors with an MD or DO who specialize in mental health. Psychiatrists can diagnose mental health conditions and prescribe medicine.

Psychiatric-Mental Health Nurse Practitioners: Advanced practice nurses with special training in mental health. Depending on state rules, they may diagnose conditions, prescribe medicines, and provide ongoing care.

Licensed Psychotherapists: This group can include licensed clinical social workers and licensed mental health counselors. They assess symptoms and provide therapy, and their authority to independently diagnose can vary by state and license.

At Author Health, psychiatric clinicians help guide evaluation and treatment while working with the rest of the care team and, with permission, the person’s established primary care clinician.

Why your medication list matters

One of the most helpful things you can bring is a complete list of your medicines.

Include:

• Prescription medicines
• The dose of each medicine
• Who prescribed it
• Over-the-counter medicines
• Vitamins and supplements

This matters because medicines can sometimes affect mood, memory, sleep, or thinking. Older adults are also more likely to take many medicines at once, which makes a careful medication review important.

Do not stop taking prescriptions on your own. The list simply gives your clinician more information to work with.

How to prepare for your first appointment

You do not need to show up with a folder full of paperwork. But a few notes can make the visit easier.

Write Down What’s Changed

Write down when the change started, how often it happens, and whether it is getting better or worse.

• “My sleep started getting worse about two months ago.”
• “I have stopped wanting to see friends.”
• “Mom has asked the same questions more often since June.”
• “I feel worried most afternoons.”

Write Down Past Care

Take note of your personal health history to help you cover everything you feel is important in the assessment.

• Past mental health diagnoses
• Therapy you have tried
• Medicines you have taken and if they helped or not
• Recent hospital stays
• Allergic reactions or side effects you’ve experienced before

Write Down Family History

If mental health or memory conditions run in your biological family, share what you know. It is okay if you do not know much. This information can help, but it is not required.

Write Down Your Questions

Write down two or three things you want to understand. You might ask:

• “What could be causing these changes?”
• “Do I need any other tests?”
• “What kind of care might help?”
• “What should my family watch for?”
• “What happens next?”

What happens after the evaluation?

You may receive a diagnosis after the first appointment. Other times, the clinician may need more information. Getting the right answer sometimes takes time, especially when symptoms could be connected to several different health conditions.

They may want to meet with you again, review medical records, use a screening tool, talk with another clinician, or recommend more testing. There is no single test that can diagnose every mental health condition.

Once your care team has a clearer picture, you can talk about what comes next.

If something feels different, that is enough to start the conversation.

Author Health helps older adults and families understand changes in mood, memory, behavior, and daily life. The goal of an evaluation is not just to name what is happening. It is to help you and your care team understand what may be going on and decide on a helpful next step.

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