Mental Health Assessment Example

Mental health assessment example

Authored by Dr. Hannah Lin, a counseling psychologist trained in CBT, ACT, and IFS. Her clinical interest is modality fit: when to switch a framework, and when to stay.

Educational content for licensed clinicians. Not clinical, legal, billing, or licensure advice. The person in the note is fictional. Adapt every line to the person in front of you, your board, your setting, and the record rules that actually govern the hour.

You write a mental health assessment example when the first hour has to stand alone. A covering clinician should see why he came, what the history changes, what you observed, the risk you asked, the diagnosis you will sign, and the next step you named. If a colleague asks for a clinical assessment example, a sample clinical assessment, or psychiatric evaluation examples, hand them this shape. Do not hand them a code description and call it the note.

The six headings are the note. The biopsychosocial assessment example is a different job: biological, psychological, and social contributors written as a formulation. Use that when the question is how the pillars interact. Use the filled note above when the question is what you sign after the first hour.

What the six sections are doing

The reason for the evaluation comes first. J.N.’s presenting line is that reason. The mental status is the review from this hour: mood, anxiety, thought content and process, perception, and cognition, written as what you saw, not as the words “within normal limits.” History holds the treatment line a covering clinician would otherwise have to re-ask: prior diagnoses, what was tried and for how long, and any hospitalization or emergency visit. If you want the domain list on one page before you write, use the mental status exam cheat sheet.

Substance use is its own line in this note, not a box you check because the form has a space. He was asked about tobacco, alcohol, other substances, and misused prescriptions. His Friday beers matter because he already noticed they worsen the 3 a.m. wake. That is a fact from this hour. It is not a substance-use disorder you have established.

Name the primary care clinician and the lab you do not have. He has Dr. Alvarez. No TSH is in the packet, so the ask is a lab, not a medical diagnosis you did not make. One sentence on why he came is enough: his family “does not do therapy,” and his partner is why he is here. Do not write a cultural formulation you did not do.

The diagnosis section names what you will sign. It does not paste a criterion list. Record duration, the symptoms you heard, the impairment, and the differentials you considered and did not use today. A pasted list is not the interview. If the chart needs an ICD-10-CM title, the CMS MS-DRG v42.1 definitions manual lists F32.1 as major depressive disorder, single episode, moderate (ICD-10-CM/PCS MS-DRG v42.1 definitions manual). That list names the title. It does not pick the code. Defend moderate with function. He is still teaching. The essays are late. That is the severity argument in this chart. The PHQ-9 of 14 is the PCP’s number. It does not choose the code for you.

Name the framework, or the plan is a placeholder

The recommendations are where a mental health assessment example either names the move you will make or stops at “weekly therapy.” Weekly therapy is not a framework. I name CBT here because the hour showed a guilt thought and a stack of essays he will not start. Behavioral activation is the 25-minute block and the Saturday walk. The thought record is one sentence, not a packet.

The offer written in the recommendations is psychotherapy or a medication conversation with Dr. Alvarez. He chose therapy. If you do not prescribe, write the medication line as his plan to raise it on Thursday. Deciding the drug for him is not your line.

I do not open with ACT on this presentation. ACT fits when someone wants to carry a thought and still do the thing that matters. J.N. wants the essays finished and the 3 a.m. wake to stop. If a later hour shows the guilt thought getting louder under the record, a short defusion rep can join the CBT work. That is a condition. It is not a second plan you forgot to write.

I do not open with IFS either. IFS fits when a protector is blocking the interview or he is already speaking in parts. Neither happened. Mapping a depressed part before the risk line and the diagnosis are in the chart makes the next clinician hunt for the episode. Stay with CBT until the episode is the thing you are treating. Switch when the hour gives you a reason, and write the reason.

Write the differential you explained, what happens if the sleep and the guilt thought stay as they are, the options you offered, and which framework you will use. A standing weekly hour, with no framework named, does not record that conversation.

If you want a blank while you work through these sections, have the intake template sent to your inbox.

Risk the next clinician can act on

When you adapt this mental health assessment example, keep the passive wish in his words and the disposition in yours.

The risk section asks current ideas, plan, and intent, including a passive wish to die. It asks prior attempts, including one he stopped himself from starting, and prior self-injury with no suicide intent. It asks whether he has thoughts of hurting someone else. Those asks are sentences. They are not a number called a disposition.

Outpatient is a judgment: passive thought, no plan, no intent, no firearm, ibuprofen moving to the partner, partner told with his consent, next visit in six days. If you need the wider frame, domains, protective factors, and when to escalate, use the mental health risk assessment guide. If the picture changes and you sit down to write a collaborative safety plan, use the Stanley-Brown safety plan template. Do not paste a blank plan into this note and call the risk section done.

A missed October 12 visit is part of the risk record. Write who calls, and what you will do if he does not answer. In this case the partner has the passive thought and the next date. That is the continuity line. It is not a crisis protocol. If the picture becomes immediate danger, follow the emergency steps your setting already uses.

When the history opens a trauma question

He gave you one accident at 19 and denied current intrusion, avoidance, and a startle tied to it. That is enough for today. A trauma battery in the first hour, when he came because the essays stopped, takes the interview away from the episode you can already name.

If a later hour opens that accident, or a childhood event he has not named, do not invent a screen in the chart. Pick by age and who can report, then order the publisher form. The list, with cost and the official link, is tests for childhood trauma. Write the name of the screen, the date, the score, and the next step. “Trauma history negative” with no question under it is how a later clinician misses the accident line you already heard.

Copy the blank lines

The blank you print is the biopsychosocial assessment template. It holds biological, psychological, and social fields plus risk, mental status, diagnosis, and the initial plan. Fill the six lines above first, so the blank does not become a stack of empty boxes with a signature under them.

If the question is the code

Some readers arrive wanting psychiatric evaluation examples and leave with a CPT question. The clinical write-up is the note above. The code, who may report it, and the frequency limits live on the psychiatric diagnostic evaluation code page. Do not copy a code rule into the recommendations and call that a plan. The plan is the framework, the step, and the next date.

If you want a draft of these six sections to edit before you sign, documentation features can start the skeleton from the hour. You still choose CBT, ACT, or IFS. You still cut any line you did not ask. You still sign.

Download the blank intake

Walk the mental health assessment example once before you print anything. Then use the blank for the next new person, and keep J.N.’s wording as the model for how specific a line has to be. A checkbox without his sentence is not an assessment.

References

• Centers for Medicare & Medicaid Services. (n.d.). ICD-10-CM/PCS MS-DRG v42.1 definitions manual. https://www.cms.gov/icd10m/fy2025-version42.1-fullcode-cms/fullcode_cms/P1321.html