Mental status exam 2026

1. Click ‘Get Form’ to open the mental status exam in the editor.
2. Begin by entering the client’s name and number at the top of the form. This personalizes the document and ensures accurate tracking.
3. Fill in the start time and setting of the exam, selecting either Residential or Outpatient as appropriate.
4. Evaluate appearance by checking options for cleanliness and age perception. Note any observations under 'Other' if necessary.
5. Assess orientation, memory, attention, and perception by marking adequate or inadequate based on your evaluation.
6. Document cognitive performance and thought processes, ensuring to note any abnormalities such as delusions or hallucinations.
7. Indicate any danger to self or others by selecting relevant options from the provided list.
8. Complete sections on speech, mood, affect, insight into problems, behavior during interview, additional observations, client strengths, service needs, provisional impression/diagnosis, and plan of treatment.

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