Assignment

http://www.psychpage.com/learning/library/advpract/interview.html

http://www.psychpage.com/learning/library/assess/mse.htm

http://www.psychpage.com/learning/library/advpract/mse.html

http://www.psychpage.com/learning/library/assess/feelings.html

http://www.psychpage.com/learning/library/counseling/suicide.html

http://www.psychpage.com/learning/library/assess/subabuse1.htm

Benchmark Intake Report Part Two: Mental Status Exam (MSE) Assignment Template

Note: This template includes Part One of the assignment because it should be included in Part Two

Identifying Information

Client name, address, phone number, DOB, gender, marital status, occupation, work/school, work phone, emergency contact, date of interview

Reason for Referral

Referral source, reason for referral (why has the client been sent to you [e.g., consultation, clinical intake, counseling]); presenting complaint (hint: they are coming in for an evaluation)

Current Situation and Functioning

A description of typical daily activities, ability to complete normal activities of daily living (ADLs); general assessment of coping/character skills (e.g., stress management skills, emotional regulation ability; problem-solving, conflict resolution, empathy, cooperation, etc.); self-perceived strengths and weaknesses

Relevant Medical History

Previous and current medical problems (major illnesses and injuries), medications, hospitalizations, and disabilities; any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease, etc.)

Psychiatric Treatment History

Description of previous treatment received, including hospitalization, medications, psychotherapy or counseling, case management, etc. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins)

Family History

Information about the client’s family background, including information about first-degree relatives (parents, siblings), the composition of the family during the client’s childhood and

adolescence, and the quality of relationships with family members both past and present.

Social and Developmental History

Significant developmental events that may influence current problems or circumstances. This should include, as aplplicable, issues surrounding pregnancy or birth; social, behavioral, and cognitive milestones; and relational history (include interaction with peers, people in authority, academic performance, and extra-curricular activities – e.g., sports, clubs, etc.); current and previous marital/non-marital relationships, children, and social supports.

Educational and Occupational History

Schools attended, educational level attained, and any professional, technical, and/or vocational training; current employment status, length of tenure on past jobs, military service (rank and duties), job performance, job losses, leaves of absence, and occupational injuries.

Cultural Influences

Potential assessment issues (see chapter 3) when working with a diverse populations.

Mental Status Exam

Appearance and Behavior

Susan C. is a 5’4” single White female of average weight. At the time of the interview, she had a pasty white complexion and several scars from adolescent acne. She presented herself in a cooperative, friendly manner during the interview, was appropriately dressed for the season, and answered questions in a direct fashion. Her eye contact was appropriate. Psychomotor activity was within normal limits as she moved comfortably during the interview. No atypical physical characteristics were noted. Her speech patterns and expressive/receptive language were within normal limits. No evidence of current drug or alcohol intoxication was observed.

Sensorium and Mental Ability

During the interview, Susan C. appeared alert and oriented x4. While not formally assessed, she appears to have average to above average intelligence as evidenced by her vocabulary and reported GPA in college. There was no difficulty with questions assessing her recent or remote memory, or mathematical calculations. Some abstract thinking difficulty was observed in her difficulty describing what the difference was between a lie and a mistake.

Thought

Susan displayed a logical, sequential, coherent flow of thought. No tangential thinking, flight of ideas, or looseness of associations were noted. Thought content appeared to be within normal limits. No evidence of hallucinations, delusions, paranoid ideation, or ruminations was apparent. No compulsions or obsessions were reported.

Sensory Motor and Perceptual Processes

Sensory motor and perceptual processes appeared within normal limits. Susan C. was able to adequately duplicate the drawing of a clock. There was no evidence of fine motor tremor, auditory, or perceptual difficulties.

Affect and Mood

During the interview, Susan displayed a moderately depressed affect. While eye contact was appropriate, she seldom smiled even when an amusing incident occurred while we were in the office. Her voice tone had monotone qualities and she often sighed during the interview. She verbalized feeling depressed since her recent miscarriage (3 weeks ago). No history of manic-like symptoms was reported. She denied suicidal and homicidal ideation. There was no evidence of a risk for violence or impulsivity.

Self-regulation

Susan C. displayed adequate impulse control and judgment. These interview qualities are consistent with her history.