Mental Health Assessment Form Patient Information Fist Name Tast Name Patient ID encly Patient Skilis/Strengths Presenting Problems Presenting Mental Health Problem(s) History of Presenting Problem(s) Current Symptoms Goals for Treatment Medical History Current Medications Medication Name __ Dose Frequency _ Indication Note Medical History http:/Carepatron.com Powered by (§ficarepatronPatient Information First Name Tast Name Pationt ID Einriliy Medical History (Continued) Family History Developmental History (If Applicable) Psychological History Personal History Family History Psychosocial History Education/Vocation| ‘Social Relationships Living Situation Developmental History Childhood/Adolescence Cultural Factors http://Carepatron.com Powered by (§ficarepatronPatient Information First Name Tast Name Pationt ID Ennely ‘Substance Abuse History Substance Age of First Use Frequency Date of Last Use Note Risk Screening Select all that applies Csuicide/Sett-harm LiNeglect/Abuse Li substance abuse Lcognitive impairment Tl Absconding risk (it inpatient) Li substance use CRIsk to dependent children (it applicable) C] Forensic and legal history Dcuttural isolation CHomelessness O Other: Wany of the above Is selected, please elaborate Mental Status Examination Observations Appearance Neat C1Disheveled C1 inappropriate) Bizarre Dother: Speech Normal ClTangential_ C)Pressured Cl impoverished LJ Other: Eye Contact, Normal intense Avoidant‘ Other: Motor Activity Normal CRestiess Tics D stowed Dotter: Affect Drui — CConstrcted Fiat Diatie Dotter: ‘Comments: Mood Deuthymic Clanxious (Angry C1Depressed Cl Euphoric Llirritable L) other: ‘Comments: ‘Cognition Orientation Impairment L]None 1) Place Dodject OPerson OTime Memory Impairment [None [)Short-term C)Long-term LC] Other: Normal Distracted Other: http://Carepatron.com Powered by (§ficarepatronPatient Information First Name Tast Name Pationt ID Ennely Mental Status Examination (Continued) None Diauditory Visual Dotter: TiNone Li Derealization L)Depersonalization Thoughts Suicidality Done Dideation —_ OPlan Dintent Disett-harm Homicidality None DiAggressive Dlintent OPian Delusions ONone OGrandiose Paranoid Religious L)Other: ‘Comment Behavior Dicooperative EGuarded Hyperactive CAgitated CParanoid Ci Stereotyped Di Aggressive Deizare — Cwithdrawn other: ‘Comments: Insight ‘Comments: Dicood Orair C1 Poor Judgment ‘Comments: Cicood HFair C1 Poor Physical Examination Results http://Carepatron.com Powered by (§ficarepatronPatient Information Fit Nae Tat Warne Patent ID Enna ‘Assessment Summary Plan/Notes inican Name ‘inican Besiaan Cina Sigpatae Date http://Carepatron.com Powered by (§ficarepatron