Social work paper (Charity only) no more thank 5 pages (follow instuctions each question must be answered) Copy Scape will be used
Things you should note MENTAL STATUS EXAM - STAFF NOTES ONLY
|
APPEARANCE |
EYE CONTACT |
INSIGHT |
ORIENTATION |
|
Appropriate |
Appropriate |
Excellent |
_ Time |
|
_ Meticulous |
_ Fair |
Moderate |
_ Place |
|
Bizarre |
Inappropriate |
Little or none |
_ Person |
|
Seductive |
Unable to determine |
Unrealistic |
_ Situation |
|
Disheveled |
|
Unmotivated for treatment |
|
|
_ Clean |
MOTOR ACTIVITY |
Does not know why he/she is here |
THOUGHT CONTENT |
|
Dirty |
_ Normal |
Appropriate for developmental age Unable to determine |
_ Unremarkable |
|
|
Overactive |
|
_ Phobia / fears |
|
AFFECT |
Tremor |
|
_ Obsessive Ideas |
|
With appropriate range |
Posturing |
DELUSIONS |
_ Feelings of unreality |
|
Depressed |
_ Tics |
None Apparent |
_ Worthlessness |
|
_Flat |
Poor coordination |
_ Persecution |
_ Hopelessness |
|
_ Angry |
_ Repetitive acts |
Grandeur |
_ Somatic complaints |
|
_ Blunted |
_ Slow |
_ Influence |
_ Persecutory |
|
Constricted |
_ Agitated |
_ Somatic |
_ Paranoid |
|
~ Labile |
Catatonic |
Religious |
Religiosity |
|
_ Incongruent |
_ Restless |
_ Other |
Sexual Preoccupation |
|
Anxious |
Involuntary movement |
|
_ Guilt |
|
_ Elevated |
_ Other |
HALLUCINATIONS |
_ Compulsions |
|
Other |
|
|
Ideas of Harm |
|
|
SPEECH |
_ Denies _ Denies but suspected by clinician |
_ Other |
|
MOOD _ Euthymic |
Normal _ Pressured |
_ Auditory Visual |
SUICIDAL IDEATIONS |
|
_ Apathetic |
Loud |
_ Olfactory |
_ None reported |
|
Depressed |
Soft |
_ Tactile |
Thoughts |
|
Elevated |
Over productive |
Gustatory |
|
|
_ Dysphone |
Under productive |
_Unable to determine |
|
|
|
|
|
|
|
Angry |
Slurred |
Other |
Plan |
|
_ Anxious |
_ Mutism |
|
|
|
Other |
Stammering _ Other |
THOUGHT PROCESS Logical / coherent |
Means |
|
|
|
|
|
|
MEMORY |
|
Blocking |
|
|
|
INTELLECT |
Circumstantial |
|
|
Intact |
|
Tangential |
Intent |
|
_ Confused |
_ Above average |
_ Rambling |
|
|
Distracted |
Average |
|
|
|
Amnesia _ Poor Immediate _ Poor Remote |
_ Below average _ Mental Retardation Unable to determine |
Perse veration _ Flight of ideas _ Loose associations Indecision |
HOMICIDAL IDEATIONS |
|
_ Confabulation |
|
Unable to determine |
_ None reported |
|
|
INTELLECT DETERMINED |
Other |
Thoughts |
|
ATTENTION |
_ Intellect is estimated |
|
|
|
_Good |
Intellect is measured |
INTERVIEW BEHAVIOR |
Plan |
|
Fair |
|
_ Cooperative |
1 loll |
|
|
|
|
|
|
Poor |
JUDGEMENT |
Uncooperative |
|
|
_ Appropriate for developmental age |
_Good |
Hostile Silly |
Means |
|
Unable to determine |
_ Fair |
|
|
|
|
Poor |
Defensive |
|
|
CONCENTRATION |
Lacks social judgment |
Manipulative Evasive |
Intent |
|
|
_ Lacks personal judgment |
|
|
|
Good |
_ Appropriate for developmental Age |
Passive |
|
|
Fair |
Unable to determine |
Dependent |
|
|
_Poor |
|
Naive |
|
|
Appropriate for developmental age _ Unable to determine |
|
_ Aggressive Negativistic |
COMPETENT TO PARTICIPATE (ADULT) Yes |
|
|
|
_ Oppositional |
~_ (ADULT) No |
|
|
|
|
_ N/A -Child |
|
|
|
|
Unknown |
Based on the information obtained in this assessment it is determined that:
|~~1 Client is not in need of services at this time I I Client is not appropriate for services at this agency
I I Client is appropriate for services at this agency J Client received Orientation to services.
Staff Signature and Credentials
Employee ID #
Date
CLIENT NAME:
CLIENT ID#:
Page 8 of 8
File under Assessment
Version 5/07