Form35 - [FORM 35-Use the top of this page for your...

Info iconThis preview shows pages 1–2. Sign up to view the full content.

View Full Document Right Arrow Icon
[ FORM 35 —Use the top of this page for your letterhead.] Mental Status Evaluation Checklist Directions: Rate current observed performance, not reported, historical, or projected. Circle the most appropri- ate descriptive terms in part C, and feel free to write in others. If an aspect of mental status was not assessed, cross out the heading. Write additional observations, clarifications, and quotations in part D. Client: Date: Evaluator: Highest grade completed GED? Special education for ? Primary occupation: Other: A. Informed consent was obtained about: q The recipient(s) of this report q Confidentiality q Competency q HIPAA q Other: B. Evaluation methods 1. The information and assessments below are based on my observation of this client during: q Intake interview q Psychotherapy q Formal mental status testing q Group therapy q Other: 2. We interacted for a total of minutes. 3. Setting of the contact: q Professional office q Hospital room q Clinic q School q Home q Work q Jail/prison q Other: C. Mental status descriptors (Circle all appropriate items) 1. Appearance and self-care Stature Average
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Image of page 2
This is the end of the preview. Sign up to access the rest of the document.

This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

Page1 / 2

Form35 - [FORM 35-Use the top of this page for your...

This preview shows document pages 1 - 2. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online