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PRESENTING PROBLEM
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Chief Complaint:
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MENTAL HEALTH HISTORY
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Previous Diagnoses (if known):
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Current Symptoms
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Mood
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Sleep
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Energy
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Motivation
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Concentration/Focus
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Enjoyment in Activities:
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Anxiety
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Panic Attacks
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Suicidal Ideation/Intent/Plan (current)
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Impulsive Behaviors
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Compulsive Behaviors
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Manic or Hypomanic Symptoms
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Psychotic Symptoms:
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Trauma History:
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Sexuality and Sexual Concerns:
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Appetite
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Recent weight loss/gain
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Eating Behaviors
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Body Image
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Other relevant MH symptoms:
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Perinatal:
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Perinatal Information:
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Current MH Treatment
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Active engagement in the following treatments
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Medications
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Active Medications
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Is client compliant on medications?
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Compliance Comments:
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Mental Health Treatment History
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Brief Overview of Past Treatment Experiences
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Suicidal Ideation/Intent/Plan/Attempts (Past)
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Psychiatric Hospitalization History
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Family History of Mental Health
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Notable MH concerns in 1st degree relatives
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BRIEF SUBSTANCE USE HISTORY
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Brief SUD information
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Is a full SUD assessment required?
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SOCIAL DEVELOPMENTAL (birth to age 18)
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Upbringing/Family of Origin Information:
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Experience in School K-12 (learning disabilities, bullying, academic success/struggles, etc.)
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FAMILY CIRCUMSTANCES
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Relationships with immediate family
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Primary Support
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LIVING SITUATION
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Describe current living situation
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EMPLOYMENT
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Employment Details:
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FINANCIAL
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Financial Concerns:
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CULTURE
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Relevant Cultural Considerations:
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SPIRITUALITY/RELIGION
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Spiritual or religious belief systems:
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LEGAL
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Legal Concerns:
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MEDICAL
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Medical Concerns:
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RECREATION/LEISURE
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Recreational Activities and Leisure:
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Social/Community Engagement:
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Exercise:
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EDUCATION
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Education History:
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ADDITIONAL ASPECTS OF CARE
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Barriers to Care:
• • •
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Other (Please specify):
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Client's Strengths:
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Other (Please specify):
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Scheduling Preferences:
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MENTAL STATUS EXAM
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Orientation:
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Orientation Comments:
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Appearance:
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Appearance Comments:
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Behavior:
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Behavior Comments:
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Mood:
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Mood Comments:
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Affect:
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Affect Comments:
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Speech:
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Speech Comments:
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Thought Process:
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Thought Process Comments:
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Thought Content:
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Thought Content Comments:
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RECOMMENDATIONS
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Recommendations for care:
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GOALS
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Goals for Care:
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