Mental Status Examination

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Comprehensive mental status examination for initial assessment

Faster? Try the mental status exam builder: tap what you observe and copy a finished note

MSE mental status assessment psychiatric
Intake Forms

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1

Appearance Behavior

  • Dress: [Appropriate/disheveled/etc]
  • Grooming: [Well-groomed/poor hygiene]
  • Eye contact: [Good/poor/avoidant]
  • Motor activity: [Normal/agitated/retarded]
2

Mood Affect

  • Mood: [Depressed/anxious/euthymic/etc]
  • Affect: [Congruent/incongruent]
  • Range: [Full/restricted/blunted]
  • Stability: [Stable/labile]
3

Speech

  • Rate: [Normal/pressured/slow]
  • Volume: [Normal/loud/soft]
  • Quality: [Clear/mumbled/etc]
  • Content: [Relevant/tangential]
4

Thought Process

  • Form: [Linear/tangential/circumstantial]
  • Flow: [Logical/disorganized]
  • Blocking: [Present/absent]
  • Associations: [Loose/tight]
5

Thought Content

  • Delusions: [Present/absent]
  • Hallucinations: [Present/absent]
  • Obsessions: [Present/absent]
  • Phobias: [Present/absent]
6

Cognition

  • Orientation: [Person/place/time]
  • Memory: [Recent/remote]
  • Concentration: [Good/poor]
  • Insight: [Good/fair/poor]
  • Judgment: [Good/fair/poor]
7

Safety Assessment

  • Suicidal ideation: [Present/absent]
  • Homicidal ideation: [Present/absent]
  • Self-harm: [Present/absent]
  • Risk level: [Low/medium/high]

Mental Status Examination Example

A completed example showing how a finished mental status examination might read in practice. All client details are fictional.

1

Appearance Behavior

  • Dress: appropriate for weather and setting
  • Grooming: well-groomed
  • Eye contact: intermittent, improving as session progressed
  • Motor activity: mild restlessness (leg bouncing)
2

Mood Affect

  • Mood: "stressed out" (client's words)
  • Affect: anxious, congruent with stated mood
  • Range: full
  • Stability: stable
3

Speech

  • Rate: slightly pressured when discussing stressors
  • Volume: normal
  • Quality: clear and articulate
  • Content: relevant and goal-directed
4

Thought Process

  • Form: linear
  • Flow: logical and coherent
  • Blocking: absent
  • Associations: intact
5

Thought Content

  • Delusions: absent
  • Hallucinations: denied
  • Obsessions: persistent worry about job performance
  • Phobias: none reported
6

Cognition

  • Orientation: oriented to person, place, and time
  • Memory: recent and remote memory intact
  • Concentration: mildly impaired (lost track of questions twice)
  • Insight: good
  • Judgment: good
7

Safety Assessment

  • Suicidal ideation: denied
  • Homicidal ideation: denied
  • Self-harm: denied, no history
  • Risk level: low

How to Use This Template

  1. 1

    Review the template structure

    Familiarize yourself with the sections and their purposes before your session.

  2. 2

    Customize for your practice

    Click "Edit & Download" to modify the template to fit your specific needs and clinical approach.

  3. 3

    Save and reuse

    Download as PDF for immediate use, or use within HIPAAtherapy to auto-fill client details and save to your records.

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