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Brief Mental Status Exam (MSE) Form
(tick all items that apply, add notes as needed)
Client Name:
Date:
1. Appearance Casual dress, normal grooming and hygiene
Other (describe):
2. Attitude Calm and cooperative
Other (describe):
3. Motor Behavior No unusual movements or psychomotor changes
Other (describe):
4. Speech Normal rate; tone; volume; w/out pressure
Other (describe):
5. Affect Normal range
Consistent with mood (mood congruent)
Labile
Tearful
Constricted
Flat
Other (describe):
6. Mood Normal or euthymic
Anxious
Irritable
Depressed
Elevated
Other (describe):
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7. Thought Processes Linear and goal-directed;
Tangential; Loosening of associations; flight of ideas
Other (describe):
8. Thought Content Suicidal ideation: Homicidal ideation:
None None
Passive Passive
Active Active
If active: yes/no is there: If active: yes/no is there:
Plan Plan
Intent Intent
Means Means
Delusions
Obsessions/compulsions
Phobias
Other (describe):
9. Perception No hallucinations or delusions during interview
Other (describe):
10. Orientation Oriented: time, place, situation
Other (describe):
11. Memory/
Concentration
Short-term memory intact
Long-term memory intact
Attentive
Distractible/inattentive
Other (describe):
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12. Insight/
Judgement
Good
Fair
Poor
Describe:
Practitioner
Signature:
Date:
Dr. Jeffrey Gaines
Shannon Fife
