Download Mental Status Form

Performance Plus
Employee Assistance Programs
Clinical Assessment
Client Name:
SS#:
Address:
City:
Place of Employment:
Phone #:
PRESENTING PROBLEM:
PSYCHOLOGICAL/EMOTIONAL SYMPTOMS and MENTAL STATUS
Current Signs and Symptoms: 0=None 1=Mild 2=Moderate 3=Severe
Depressed Mood
Appetite Disturbance
Sleep Disturbance
Elimination Disturbance
Low Energy
Psychomotor Retardation
Agitation
Lability
Irritability
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Generalized Anxiety
Panic Attacks
Phobias
Obsessions/Compulsions
Bingeing/Purging
Anorexia
Paranoid Ideation
Circumstantial/Tangential
Loose Associations
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
Organicity Indicators:
2
2
2
2
2
2
2
2
2
Oriented x 3
Impaired Memory
Other Cognitive Impairment
Specify:
Delusions
Hallucinations
Aggressive Behaviors
Conduct Problems
Oppositional Behavior
Sexual Dysfunction
3
3
3
3
3
3
3
3
3
 Yes
 Yes
 Yes
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
 No
 No
 No
3
3
3
3
3
3
RISK ASSESSMENT: (Check any risk that has occurred in the past 3 months. Elaborate on any positive findings).
Client Status:

Suicidal Risk
Homicidal Risk






 None
 Ideation
 Intent
 Plan
 Means
 Attempt
None
Ideation
Intent
Plan
Means
Attempt
Victim
 Perpetrator
Abuse:physical/sexual






 Both
Domestic Violence






None
Ideation
Intent
Plan
Means
Attempt
None
Ideation
Intent
Plan
Means
Attempt
Threat Of Violence Level: (Check applicable level)


1-Assesed: no indicators  2-Possible threat mentioned: no current danger
4-Active threat of violence exists  5-Client is dangerous to self/others
CONTRIBUTING FACTORS:
 Substance Abuse
 Legal Problems
 Medical Problems
 Grief/Loss
RELEVANT HISTORY:
 Family Conflicts
 Work Relations

3-Threat made: possibility of violent action
exists
 Parenting Problems
 Sexual Abuse
 Financial Stress
 Domestic Abuse
Clinical Assessment (pg 2)
Client Name:
Place of Employment:________________________________
CLIENT STRENGTHS/LIMITATIONS
PROVISIONAL CLINICAL DIAGNOSIS
DSM-IV (Use codes & DX)
AXIS I:
______________________________________________________________________ __
AXIS II:
____________________________________________________________ ____________
AXIS III:
_______________________________________________________________________ _
AXIS IV:
_____________________________________________________________ ___________
AXIS V:
________________________________________________________________________
ASSESSMENT SUMMARY
REFERRAL PLAN:
Counselor Signature
Date