Mental Status Exam Template

Comprehensive mental status examination for initial assessment

Faster? See normal and abnormal mental status exam examples, or build the note as you go

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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