Mental Status

Appearance:

Demeanor/ Attitude:

Motor Activity

Mood

Well Groomed

Unremarkable

WNL

Appropriate

Depressed

Disheveled

Belligerent

Agitated

Anxious

Inappropriate

Guarded

Tremors/Tics

Angry

Psychomotor Retardation

Affect

Anxiety

Depression

Cognitive Function

Appropriate

WNL

Suicidal

Intact

Expansive

High

Psychotic Features

Impaired

Labile

Paranoia

Constricted

Orientation

Memory

Judgment

Insight

Fully Orientated

Intact

Intact

Intact

Somewhat Impaired

Impairment

Impaired

Impaired

MEDIAL/PSYCHIATRIC HISTORY

Medical History:

Medication

Psychiatric History

Medication

Drug/Alcohol History:

No

Yes

Substance Abuse Assessment:

No

Yes

Family Alcohol/Drug History:

No

Yes

Work History/Performance Issues:

No

Yes

Financial/Legal:

No

Yes

History of Abuse:

No

Yes

Suicidal Risk Assessment:

Ideation

No

Yes

Plan

No

Yes

Assessment/Intervention Plan:

Significant Notes:

Counselor's Signature

Date