Assignment

Client Name (First, MI, Last)

Account No.

NOTE: Record level of severity next to abnormal findings. 1 = Mild, 2 = Moderate, 3 = Severe, X = Normal Finding

General Observations

Appearance

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Well Groomed

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Unkempt

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Disheveled

Build

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Average

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Thin

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Overweight

Demeanor

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Average

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Hostile

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Mistrustful

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Withdrawn

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Preoccupied

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Demanding

Eye Contact

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Average

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Avoidant

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Intense

Activity

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Average

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Agitated

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Slowed

Speech

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Clear

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Slurred

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Rapid

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Pressured

Thought Content

Delusions

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Grandiose

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Persecutory

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Somatic

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Bizarre

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Nihilistic

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Religious

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None Reported

Other

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Autistic

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Obsessional

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Phobic

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Guilty

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Ideas of Reference

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None Reported

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Preoccupied

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Guarded

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Other:

Self Abuse

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Suicidal (assess lethality if present):

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Intent

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Plan

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Self-Mutilation: _________________

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None Reported

Aggressive

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Aggressive (assess lethality if present):

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Intent

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Plan

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None Reported

Perception

Hallucinations

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Auditory

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Visual

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Olfactory

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Gustatory

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Tactile

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None Reported

Other

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Illusions

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Depersonalization

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Derealization

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None Reported

Thought Process

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Logical

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Circumstantial

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Tangential

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Loose

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Racing

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Incoherent

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Concrete

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Blocked

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Flight of Ideas

Mood

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Euthymic

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Depressed

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Anxious

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Angry

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Euphoric

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Irritable

Affect

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Full

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Constricted

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Flat

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Inappropriate

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Labile

Behavior

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Cooperative

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Resistant

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Agitated

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Impulsive

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Over Sedated

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Assaultive

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Aggressive

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Hyperactive

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Restless

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Loss of Interests

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Anhedonia

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Akasthisia

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Withdrawn

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Dystonia

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Tardive Dyskinesia

Cognition

Impairment of:

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Orientation

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Memory

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Attention/Concentration

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Ability to Abstract

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None Reported

Intelligence Estimate

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MR

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Borderline

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Average

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Above Average

Insight/Judgment

Elaboration of Positive Mental Status Findings

Therapist Signature/Credentials

Date