Initial psychiatric evaluation
Psychiatric Evaluation in Maplewood, NJ
A 60–90-minute comprehensive evaluation grounded in DSM-5-TR, delivered by a board-certified PMHNP. You leave with a diagnosis, a treatment plan, and — if medication is indicated — same-day prescriptions for non-controlled substances.
- DSM-5-TR diagnostic framework
- Same-visit treatment plan
- Telehealth or in-person
Psychiatric evaluation
What a psychiatric evaluation means here.
A comprehensive psychiatric evaluation is a 60–90-minute clinical assessment designed to understand the whole person — not to assign a label. It integrates clinical history, mental status examination, and validated screening instruments to produce a diagnostic formulation and a collaborative treatment plan grounded in the DSM-5-TR (American Psychiatric Association, 2022). It is the most thorough visit we offer and the starting point for almost every new patient at our practice.
This is not a fifteen-minute primary-care depression screen. Your PCP does excellent work catching the obvious cases with a PHQ-9 and first-line SSRI. A psychiatric evaluation is what you need when the picture is more complicated: multiple symptom clusters, prior medication trials that didn't work, co-occurring substance use or trauma history, a diagnosis that doesn't feel quite right, or a second opinion before starting a more serious treatment course. The goal is a formulation — a narrative understanding of how biology, psychology, and social context interact in your specific presentation — not a symptom count.
All evaluations are conducted by Teresa Omwenga, PMHNP-BC. Because she is the prescribing clinician, diagnosis and the first prescription (if medication is indicated) happen in the same visit — no second appointment, no handoff to another provider. That same-visit integration is the most important structural difference between evaluations here and the split-care model common in larger practices. Most patients transition directly into ongoing medication management after the evaluation.
Why you might need one
Situations that call for a full psychiatric evaluation.
There are seven common reasons patients schedule an evaluation with us. Persistent mood changes — two weeks or more of depression, irritability, or mood instability — that aren't responding to therapy or lifestyle changes. Sleep or focus disruption that is affecting work, school, or relationships and hasn't resolved with sleep hygiene or behavioral changes. Recurrent panic attacks with or without agoraphobia. A suspected diagnosis (adult ADHD, bipolar spectrum, OCD) that a primary-care provider flagged but couldn't confirm. A medication review because the current regimen isn't working or you suspect the diagnosis underneath it was wrong. A second opinion before starting a mood stabilizer, a controlled substance, or an antipsychotic. A transfer of care after moving to New Jersey or after a previous psychiatrist stopped practicing.
If you're not sure whether what you're experiencing warrants an evaluation, the free 15-minute consultation is designed for exactly that conversation. We'll listen, ask a few questions, and say honestly whether an evaluation is the right next step or whether something else (your PCP, a therapist, a specific specialist) fits better.
#assessment
Psychiatric evaluation vs psychological assessment.
The terms get used interchangeably in casual conversation, but they refer to distinct services. A psychiatric evaluation is what we provide — a 60–90-minute clinical diagnostic interview conducted by a psychiatric prescriber (PMHNP or psychiatrist) that yields a DSM-5-TR diagnosis and a treatment plan that may include medication. A psychological assessment (also called neuropsychological testing) is a multi-hour formal testing battery conducted by a licensed clinical psychologist — it uses instruments like the WAIS, Wechsler Memory Scale, MMPI-2-RF, or Rorschach to answer specific referral questions about IQ, learning disabilities, detailed cognitive profile, or personality structure.
When does someone need formal psychological testing? Common referral reasons include a suspected learning disability in a teen struggling academically despite stimulant treatment for ADHD; forensic questions (capacity, disability, accommodations); complex presentations where a psychiatric evaluation suggests a broad differential that testing could narrow; and pre-surgical or pre-transplant clearances. If any of these fits your situation, we'll conduct the psychiatric evaluation first to clarify the question and then refer you to a trusted NJ-based clinical psychologist for the testing itself.
Neuropsychological evaluation is a third, narrower term — it refers to specialized testing for suspected brain injury, dementia, stroke sequelae, or seizure-related cognitive change, typically conducted by a neuropsychologist and sometimes in coordination with neurology. We refer for these when indicated.
Your intake timeline
What the 90 minutes actually look like.
Every initial evaluation runs the same basic structure. Knowing the timeline ahead of time reduces anxiety, and it lets you know whether we’re running on track during the visit itself.
Before the visit
After you book, you'll receive an intake packet to complete online: basic demographics, insurance verification, a medication list (including over-the-counter supplements), and a small set of validated self-report screeners — most commonly the PHQ-9 (depression), GAD-7 (anxiety), and MDQ (bipolar spectrum). If your presenting concern suggests ADHD or PTSD, you'll see the ASRS v1.1 or PCL-5 respectively. These take 5–15 minutes total and arrive at your visit as baseline data. If you have records from previous psychiatric care, uploading them in advance lets us review before you arrive.
The first 20 minutes
We start with the presenting concern — what brought you in, how long it's been going on, what has made it better or worse, and what is different now. A safety screen is embedded early, using the Columbia-Suicide Severity Rating Scale for any patient with mood or trauma symptoms. This part is conversational, not interrogative; the data collection comes later, once we understand what you're actually asking for.
The middle 40 minutes
The bulk of the evaluation is structured history-taking. We work through past psychiatric history (prior diagnoses, all medications tried, response, side effects, hospitalizations), medical history (thyroid disease, sleep apnea, seizure disorder, current medications including OTC and supplements, allergies), family psychiatric history, substance use, developmental and social history, and trauma history (with your consent). Then we conduct a formal mental status examination — appearance, behavior, speech, mood and affect, thought process and content, cognition, insight, and judgment. Validated screening instruments are reviewed in context of the full clinical picture; a positive PHQ-9 indicates symptoms, not a diagnosis.
The final 20 minutes
Diagnostic discussion, case formulation, and treatment planning together. We explain what we think the DSM-5-TR diagnosis is — or that we need more information before we can commit (labs, records from prior providers, a follow-up visit to watch how symptoms evolve). We walk through treatment options: medication if indicated, therapy coordination, lifestyle interventions, and any specialist referrals. If you're comfortable starting medication and it's not a Schedule II controlled substance, the prescription goes out the same day. You leave with a written plan — diagnosis, rationale, medication name and dose if applicable, follow-up timing, and what to watch for in the first two weeks.
What we assess
The biopsychosocial domains we cover.
A comprehensive evaluation is biopsychosocial — biology, psychology, and social context are each explored because each shapes treatment. Biology includes current symptoms (onset, severity, duration, daily impact), past psychiatric history (every prior diagnosis, treatment, response), medical history (especially conditions that can mimic or worsen psychiatric symptoms: thyroid disease, B12 deficiency, sleep apnea, seizure disorder, traumatic brain injury), medication history (including OTC and supplements; St. John's Wort can meaningfully interact with SSRIs), family psychiatric history (first- and second-degree relatives), and substance use.
Psychology covers cognition (focus, memory, executive function), personality traits that may shape treatment response, coping style, and thought process. Social context includes developmental history (prenatal and birth events, milestones, childhood adversity), education and occupational history, relationships and housing stability, legal history, and cultural or spiritual context. Trauma history is screened with informed consent — we don't dig unless you want to and feel ready.
Functional impact is its own domain. A person can score high on depression and anxiety symptom measures and be functioning fine at work and in relationships; another can score lower and be barely holding together. The treatment plan weights symptoms and function together.
Screening instruments
Validated tools we use.
Screening instruments are dimensional measures that anchor the clinical picture in data. They are not diagnostic on their own — a positive PHQ-9 does not confirm major depressive disorder, and a negative ASRS does not rule out adult ADHD. Used alongside clinical interview and the DSM-5-TR criteria, they give us a shared baseline to measure change from.
PHQ-9 (depression severity, 9 items, cutoff ≥10). GAD-7 (generalized anxiety, 7 items, cutoff ≥10). MDQ (bipolar spectrum screening, 13 items; positive result prompts fuller mania/hypomania inquiry). ASRS v1.1 (adult ADHD screener, 6 items; ≥4 positive items on Part A warrants full ADHD evaluation). PCL-5 (PTSD symptoms, 20 items, cutoff ≥38). Y-BOCS (OCD severity for established diagnoses). C-SSRS (suicide risk, structured inquiry, validated across adolescents/adults/elders). AUDIT + DAST-10 (alcohol and drug use screening). MoCA (cognitive screening for older adults; more sensitive than the MMSE for mild cognitive impairment).
Which instruments you complete depends on your presenting concern. A new patient with focus and organizational concerns gets the ASRS; a new patient with mood symptoms gets the PHQ-9, GAD-7, and MDQ. Every patient gets a structured suicide-risk screen. We repeat the relevant instruments at follow-up visits so progress is measured, not just remembered.
After the evaluation
What happens next.
Because the evaluation concludes with an integrated treatment plan, there is no second appointment needed to “discuss results.” If medication is indicated and you're ready to start, a non-controlled prescription is sent to your pharmacy the same day. If the indicated medication is a Schedule II controlled substance and you're an adult on telehealth, we schedule the required in-person follow-up visit in Maplewood before prescribing begins. If therapy is indicated and you don't already have a therapist, we'll make two or three concrete referrals to NJ-based clinicians with openings; you book directly with them.
Follow-up from the evaluation looks like this: if you're on a new medication, a 2-week check-in (telehealth is fine), then a 4-week visit, then every 4 weeks during active titration. Once stable, we move to every 2–3 months for maintenance. If no medication is started, we may not see you again for six months unless you want to return sooner; you are not locked into ongoing care.
The written visit summary is available in your chart within 48 hours. It includes the DSM-5-TR diagnosis, rationale, screening results, treatment plan, and next steps. You can request a copy for your records, and with your written consent, we can send it to your primary care provider or existing therapist.
Telehealth evaluation
Evaluations by video, when in-person isn’t practical.
Psychiatric evaluations can often be conducted effectively by video when the presentation is appropriate for telehealth. The evaluation runs the same 60–90 minutes, covers the same biopsychosocial domains, uses the same screening instruments when indicated, and results in the same integrated treatment plan.
Telehealth is available to patients physically located in New Jersey at the time of the visit. Technical requirements are modest: a smartphone, laptop, or tablet with a camera; a reliable internet connection; and a private room where you can speak freely for 90 minutes.
In-person evaluation is preferred for a small subset of presentations: acute psychotic symptoms, severe agitation or crisis, and situations where in-person observation is clinically valuable (suspected movement disorders, extrapyramidal symptoms, or significant cognitive decline). For these, we'll recommend an in-person visit and, if you can't come to Maplewood, refer to a closer clinician.
Second opinions
Bringing records from prior treatment.
Second-opinion evaluations are welcome and common. Patients come to us for a fresh diagnostic review when the current diagnosis hasn't explained their experience, when multiple medication trials have failed, or when a significant treatment decision (starting lithium, starting an antipsychotic, electroconvulsive therapy) warrants a second perspective. We take second opinions seriously — we review your records, conduct the full evaluation, and tell you honestly whether we agree with the current diagnosis or propose a different formulation.
Bringing prior records accelerates the evaluation meaningfully. Useful documents include prior psychiatric evaluations or discharge summaries, current and prior medication lists with doses and durations, recent relevant labs (thyroid panel, B12, lithium/valproate levels if applicable), and any formal psychological testing you've had done. If you don't have records and can't easily obtain them, we work with what we have — but a good records review often prevents repeating a trial of medication that already didn't work.
Diagnostic humility
When we don’t give you an answer on day one.
Most evaluations produce a clear DSM-5-TR diagnosis in the final 20 minutes. Some don't, and that's clinically appropriate. Bipolar spectrum conditions often need a longitudinal view — is this recurrent depression or the depressive pole of bipolar II? ADHD with co-occurring anxiety can be hard to disentangle in one visit; sometimes we treat the more prominent condition first and watch what clears. Early psychosis can look like severe anxiety with unusual features and benefits from careful follow-up before a psychotic-spectrum diagnosis is committed to a chart.
When the diagnosis is uncertain, we say so explicitly. You'll leave with a working formulation (“we're considering X, but Y and Z remain on the differential”), a plan to gather specific data (labs, records from prior providers, a structured follow-up to observe symptoms), and a treatment recommendation that makes sense given what we know now. Starting treatment on a provisional diagnosis is sometimes the right call — especially when symptoms are severe and the candidate medications overlap across the differential. We explain that reasoning in plain language so the provisional status is not a surprise later.
Diagnostic revision is a normal part of psychiatric care. If new information arrives at a follow-up — a manic episode that wasn't captured at intake, a medical workup that turns up a thyroid issue, a family history revelation — we update the diagnosis in the chart and adjust the plan accordingly. The goal is the right diagnosis, not the first diagnosis.
Fees & Insurance
Transparent pricing. 18 plans listed — verification required.
Know exactly what care costs before you book. Sliding-scale available for out-of-pocket patients; superbills provided for out-of-network reimbursement.
Initial evaluation
$210
~90 minutes
Comprehensive psychiatric intake. History, symptoms, goals, and a shared treatment plan.
Free introductory call
Free
15 minutes · no obligation
A brief call to see if we're a good fit. Ask questions. Decide at your pace.
Follow-up visit
$130
~30 minutes
Ongoing medication management, adjustments, and supportive care as needed.
18 plans listed
Insurance directories can lag behind actual credentialing status. We verify your specific plan and benefits during the free 15-minute consultation before any paid visit. If your plan isn't listed, ask about a superbill for possible out-of-network reimbursement.
- Aetna
- Anthem
- Blue Cross
- Blue Shield
- BlueCross and BlueShield
- Cigna and Evernorth
- Empire Blue Cross Blue Shield
- Horizon Blue Cross and Blue Shield
- Medicaid
- Meritain Health
- Omnia Tier 1
- Oscar Health
- United Health Oscar Plans
- United Medical Resources (UMR)
- United Medicare
- United NJ Exchange
- United Oxford Medicare
- UnitedHealthcare UHC | UBH
Listed plans last reviewed 2026-05-01.
Payments accepted · Cash · Check · Discover · Mastercard · Visa · Zelle
Sliding scale: Sliding-scale rates are available for self-pay patients. Reductions range from 20% to 50% based on your situation. Discuss during your free 15-minute consultation — no formal paperwork required.
Cancellations: We require 24 hours' notice for cancellations. Missed appointments or late cancellations incur a $75 fee. First-time occurrences are typically waived.
Locations
Serving 9 additional NJ towns
In-person visits at our Maplewood, NJ office, with telehealth available for New Jersey residents when clinically appropriate.
Common questions
Things patients ask about the evaluation.
How long does a psychiatric evaluation take?
60–90 minutes for the initial visit. This is a comprehensive biopsychosocial assessment — current symptoms, personal history, medical history, family history, medication history, substance use, trauma history, and functioning — paired with validated screening instruments (PHQ-9, GAD-7, MDQ, Y-BOCS, PCL-5, or ASRS v1.1 depending on your presentation) and a mental status examination. We don't rush it.
What should I bring to the evaluation?
A list of current medications (name, dose, frequency) including over-the-counter and supplements; a brief list of prior psychiatric medications you've tried and why they were stopped; any recent lab work; your insurance card and photo ID; and — if you have them — records from prior mental-health providers. If none of that is available, come anyway. We can gather most of it during the visit.
Will I get a diagnosis on the first visit?
Usually yes — a DSM-5-TR working diagnosis (or differential) delivered during the final 20 minutes of the visit, along with a treatment plan. Sometimes the diagnosis is provisional pending medical workup (to rule out thyroid disease, B12 deficiency, sleep apnea, or other medical contributors) or pending records from prior treatment. In that case we start treatment on the most likely diagnosis and refine as new information arrives.
Can I get medication prescribed at the first visit?
Often yes. Because Teresa is a PMHNP-BC, diagnosis and prescribing happen in the same visit — there's no second appointment or hand-off to a different prescriber. If we reach a clear diagnosis and agree on a medication plan, prescriptions go out the same day. For Schedule II medications like ADHD stimulants, New Jersey's in-person requirement applies; telehealth evaluations can still result in a same-day prescription for non-controlled medications.
Is this the same as psychological testing?
No. A psychiatric evaluation is a clinical diagnostic interview performed by a psychiatric prescriber (PMHNP or psychiatrist) to establish diagnosis and a treatment plan — including medication if indicated. Formal psychological or neuropsychological testing (WAIS, WAIS-IV, Rorschach, extended neurocognitive batteries) is a multi-hour assessment performed by a licensed psychologist, typically to answer specific referral questions like learning disability, IQ, or complex cognitive profile. We refer out when that kind of testing is indicated.
Will my insurance cover a psychiatric evaluation?
Yes — psychiatric evaluation is covered under CPT code 90792 (with medical services) by every plan currently listed for the practice; the specific copay, deductible, and prior-authorization requirements vary by plan and we verify yours during the free 15-minute consultation. Self-pay rate for a 60-minute evaluation is $210; sliding-scale rates are available on request, and we issue superbills if you'd like to file for out-of-network reimbursement.
Can a family member attend the evaluation?
Yes, with your consent. Having a spouse, parent, or adult child present for part of the visit often adds useful history you may forget in the moment. That said, there are usually portions of the evaluation — trauma history, substance use, current stressors — where it's better to talk one-on-one. We'll work out the structure at the start of the visit.
What if I don't agree with the diagnosis?
Tell us. Diagnosis is a working hypothesis, not a verdict — it should explain your experience, not override it. If what we've concluded doesn't match how you see yourself, that's important clinical information, and we'll review the screening results, criteria, and differential with you. Second opinions are welcome and appropriate; we'll share records so another clinician doesn't start from scratch.
How do I prepare for the evaluation?
Think about three things: when did this start, what makes it better or worse, and what would 'better' look like for you? Those three questions anchor most of the visit. Don't write a script — spontaneous conversation tells us more than a prepared statement. If there's anything you'd forget to mention, jot it on a phone note or index card and bring it.
Ready to get a clear answer?
A 60–90-minute psychiatric evaluation is often the difference between years of guessing and a treatment plan that actually fits. The free 15-minute call is the first step.