Appearance

Appears to be chronological age

Weight proportionate to height

Clothing and accessories appropriate to culture and situation

Apparent nicotine stains

Dental erosion

Rash around mouth

Needle/track marks

Noticeable body odor

Body modifications _____________________________

Other _______________________

Attitude/Rapport

Excellent

Good

Fair

Poor

Mood (self report)

Angry

Anxious

Indifferent

Other ___________

Behavior

Eye contact Repeatedly glances to one side

Avoids making eye contact

Good quality eye contact

Other ____________________ Body Movements (observed)

No abnormal body movements

Tremor

Abnormal gait

Hyper activity

Tic

Other _______________

Southern Light Counseling CD Vendor# 002344001 SLC NPI# 1346513744

Mental Status Exam Property of SLC Copying without permission is prohibited

Client: DOB: SSN#: Pay Source: Legal Guardian: Relationship to Client: N/A SLC Admission Date:

Southern Light Counseling Home Court Advantage

Provider/Credentials: Clinical Supervisor/Credentials: H.C. Case Manager: Referred by:

Self CD Worker/Name/Creds/Agency: RST EAP Other

Date of Service: __________________ Start Time:____________________End time:____________________

Place of Service: 11 In Office 12 In Home 14 Residential

Other:____________________________________________________ Units of Service Provided: _____________________________

Mental Status Exam

Mood/Affect Appropriate to situation

Congruent /in congruent with thought and mood

Intensity Normal

Blunted

Exaggerated

Range of Emotional Expression Constricted Fixed

Mobile Liable

Changed affect flexibility and appropriately with flow of conversation

Yes No

Speech/(Production of speech) Para linguistic features

Pressured Rapid Loud

Prolonged Latent Soft

Spontaneous

Specific language disorders Stuttering Difficult to understand

Difficult to understand Mutism

Repeats words of others (echolalia)

Pragmatic Aspects of speech Repeats own words (palilalia)

Makes up words with specific meaning

To Self (neologism)

Thought Process Quality of Ideas

Frequent and spontaneous introduction of new viable ideas in course of conversation

A free flow of new viable ideas

A few new viable ideas presented in course of conversation

Return to same limited set of ideas

Other _________________________ Tempo

Flight of ideas noted by incoherent speech

Slow thought processing and few associations

Thoughts keep pace with conversation Form

Speech interrupted by silences (blocking)

Off the point responses (derailment)

Deviates from topic of discussion (tangentially)

Invalid reasoning (illogical)

Other ________________________

Thought Content Over valued ideas

Client holds false belief with conviction that:

Over weight

Ill

A body part is abnormal

Other _________________ Obsessions

Client unable to suppress undesired, unpleasant, intrusive thought

Other ___________________ Phobias

Client dreads a harmless object or situation

Other ________________________

Client : DOB: Provider/Credentials Clinical Supervisor/Credentials:

2

Mental Status Exam

Thought Content Preoccupations

Suicidal Ideation Homicidal Ideation

Unfounded suspicions Cognitive distortions producing anxiety/depression

Delusions General mistrust of others beliefs of conspiracy (paranoid)

Assigns personal significance to mere coincidences (reference)

Fantastical beliefs that self is famous, powerful, etc (grandiose)

Belief that a famous person is enamored with him/her and is sending confirmations of love (telepathically or otherwise) (erotomanic)

Belief that the identity of a person, object, or place has somehow changed or been altered (misidentification)

Belief that thoughts have been taken out of the client’s mind and he/she has no control over it (thought withdrawal) (controlled thought)

Feeling that thoughts are not his/her own (thought insertion) (controlled thought)

Belief that others can hear his/her thoughts (broadcasting) False self accusation (guilt)

False belief he/she is financially incapacitated (poverty)

Belief he/she has no mind or is dead (nihilistic)

Perceptions Client experiences a sensory perception as “real” in external or objective space in the absence of any external stimulus (hallucination)

Client experiences a distortion of sensory experience and may recognize it as a false perception (illusion)

Auditory Visual Tactile Olfactory Gustatory Client experiences hallucinations in internal or subjective space - voices in head (pseudo hallucination)

Auditory Visual Tactile Olfactory Gustatory Client experiences time distortion (de ja vu)

Auditory Visual Tactile Olfactory Gustatory Client experiences a distorted sense of self (depersonalization)

Auditory Visual Tactile Olfactory Gustatory Client experiences a distorted sense of reality (de-realization)

Auditory Visual Tactile Olfactory Gustatory

Client : DOB: Provider/Credentials Clinical Supervisor/Credentials:

3

Mental Status Exam

Insight Client recognizes/understands own problem

Client is compliant with Tx

Other __________________________

Judgment Client can make sound, reasonable, responsible, decisions

Client is: Impulsive Socially aware

Self aware Has ability to plan

Intellectual functioning (estimated)

Intelligence Quotient (I.Q.)

Above 70

Below 70

Adaptive functioning

Adequate level of functioning

Limitations impair level of functioning

Cognition (Refer to Mini-Mental Sate Exam Attachment) Client is: (alertness)

Alert Aware Responsive to the environment

Client is oriented to: (oriented)

Person Place Time

Client can focus on a specific stimulus, while ignoring other stimuli (attention and concentration)

Yes No

Client can remember specific information : (memory)

Immediate registration (registration – MMSE)

Short term (recall – MMSE)

Long term (orientation - MMSE)

Cognition (Refer to Mini-Mental Sate Exam Attachment

Client’s “minds –eye” correctly visualizes, recalls and learns information (visual spatial functioning)

Yes No

Client can name objects, repeat phrases and spontaneously respond to instructions (language-MMSE)

Yes No

Client can manage, regulate, control, cognitive processes (executive function)

Yes No

Client : DOB: Provider/Credentials Clinical Supervisor/Credentials:

4

Mental Status Exam

Cultural Considerations

Client’s race

White/Caucasian

Black/African American

Hispanic

Asian

Native American

Other ______________________

Client presents self in keeping with cultural background

Client : DOB: Provider/Credentials Clinical Supervisor/Credentials:

Clinician ______________________________________________________________________________________Day ________________________________Date__________________________ Signature, Credentials and State license #

Reviewed by _______________________________________________________________________________________________________________________Date__________________________ Signature, Credentials and State license #

Clinical Supervision Utilization Review

Reviewed by _______________________________________________________________________________________________________________________Date__________________________ Signature, Credentials and State license #

Clinical Supervision Utilization Review

Emailed to: _____________________________________________________________________________________________________________ Date____________________________________

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