Mental Health Assessment Form Template
Document a structured mental health assessment that supports accurate diagnosis and care planning.
A mental health assessment creates the clinical foundation for everything that follows — diagnosis, treatment planning, and referral decisions. This form gives mental health clinicians a comprehensive template to document the assessment in a structured, replicable format.
The template covers presenting concerns and onset, symptom inventory across diagnostic categories, mental status examination observations, psychosocial history, trauma history, substance use assessment, risk assessment (suicidality, self-harm, harm to others), protective factors, and the clinical formulation and preliminary diagnosis.
Consistent assessment documentation supports continuity of care, supervision, peer review, and — when records must be shared — clear communication across providers.
An MSE is a structured observation of the client's current psychological functioning, covering appearance, behavior, speech, mood and affect, thought process and content, perceptions, cognition, insight, and judgment.
Yes. Include the PHQ-9 for depression, GAD-7 for anxiety, PC-PTSD-5 for trauma screening, and AUDIT-C for alcohol use, depending on the presenting concern. Document the tool used and the score.
Thorough enough to support a clinical decision. Document ideation frequency, intent, plan, means, and protective factors. A risk assessment that notes 'denies SI' without exploring further is insufficient.
A licensed mental health clinician or supervised trainee under appropriate supervision. The scope and tools should reflect the clinician's training and licensure scope.
A comprehensive assessment is typically done at intake. Brief re-assessments occur at regular intervals — every 90 days is common — or when there's a significant change in presentation or risk.
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