Mental Health Assessment Form

Conduct comprehensive mental health assessments for your patients using our all-in-one mental health assessment form, which includes an MSE, risk assessment, medical histories, and substance use table.

Bernard Ramirez
Bernard Ramirez
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What is a Mental Health Assessment Form?

A mental health assessment is an important process to assess the current functioning of a patient, normally upon intake. The results of a mental health assessment will be invaluable in informing the clinical decision-making for the patient’s treatment. There are many different standardized assessment tools, such as MMPI-2, K10, or DASS, which are commonly used as part of a mental health assessment.

Our mental allows for more flexibility in the assessment of your patient, while still incorporating some structured elements such as medication tables, substance use tables, and a mental status exam. Use whichever parts of our mental health assessment form that you find useful, or complete the entire thing, how you use it is up to you. We have provided many important items that should be included in mental health assessments such as medical and psychosocial histories, a detailed risk assessment, physical examination results, and space for your clinical assessment of the patient.

Printable Mental Health Assessment Form

Download these templates for a Mental Health Assessment Form to improve your therapy intake process and HIPAA compliance.

How To Use This Template For Mental Health Assessment Forms

Once you’ve downloaded our mental health assessment form, work your way through the different sections in whichever order you prefer. To follow the assessment form in the given order, just follow these simple steps, and you’ll be using this form in no time.

Step One: Patient Information

Regardless of the order in which you choose to conduct the mental health assessment, we suggest you fill out the patient information first. This information is important for ensuring the medical record is assigned to the correct patient, and for dating the assessment correctly. 

Step Two: Presenting Problem and Goals Section

This section is for the specific history and presentation of your patient’s current mental health problem(s). Include your patient’s current symptoms in this section as well. We included this section at the start so you can remember your patient’s present issues at a glance, before diving into their history.

Step Three: Medical, Psychological, and Psychosocial Histories

These three sections are for building up a holistic view of your patient, both their medical and psychological history and to get an idea of them as a person through their psychosocial history. Often events in early childhood or adolescence may impact present mental health, so it is important to be thorough in taking the psychosocial history, as well as the psychological and medical histories.

Step Four: Substance Use and Risk Screening

We have included a handy table and checkbox list for completing your patient’s substance use history and risk screening. Depending on your patient, you may choose to omit any parts of this mental health assessment that do not apply to your patient. 

Step Six: Mental Status Examination (MSE)

One of the great features of this mental health assessment is it includes a mental status exam. This means you don’t have to open up multiple templates or documents, and can complete the mental status exam portion of the mental health assessment all in one place. 

Step Seven: Physical Exam Results, Assessment Summary, and Notes

The last page is for summing up, noting down your patient’s next steps, and any notes you have for the coordination of their care, or their follow-up with you. Don’t forget to sign and date this form and store it securely.

Mental Health Assessment Form Example (Sample)

This assessment form may seem overwhelmingly complex, or just too long to wrap your head around, but don’t worry; we’ve included an example mental health assessment using this form so you can see how all the different parts can come together. Remember, although this mental health assessment has a lot of different parts, the sections you choose to complete for your patient are dependent on your patient, and you do not have to complete any that are irrelevant to your patient.

Download this Mental Health Assessment Example (Sample) here: 

Mental Health Assessment Form Example (Sample)

Who Can Use this Printable Mental Health Assessment Form (PDF)?

This mental health assessment form can be used by a whole range of mental health professionals. While the mental status exam (MSE) section requires professional expertise to complete accurately, the current medications or goals sections may be completed by any qualified mental health practitioner. This could include:

  • Psychiatrists and psychiatric residents
  • Psychotherapists
  • Therapists or counselors
  • Clinical psychologist
  • Psychiatric nurses.

Due to the length of the mental health assessment, or to maximize your time management, you may have different practitioners complete different parts of the mental health assessment. Additionally, if you have professionals trained in certain specialty areas such as substance abuse or developmental psychology, it may make sense for these professionals to conduct the relevant parts of the mental health assessment.

Why is This Form Useful For Mental Health Professionals?

Organize Your Documentation

A mental health assessment includes information gathered in a range of different areas in order to build a comprehensive picture of your patient’s mental functioning. To keep all this information well organized, our form includes multiple headings, sub-headings, tables, and boxes to structure your mental health assessment.

Structure Your Session

Our mental health assessment form incorporates a section-based format to allow you to structure your session with your patient. Having a written record of what information you need to cover can be a great help for managing your session with your patient, and ensuring you don’t miss anything.

Mental Health Software Feedback

Why Use Carepatron For Mental Health Assessment Forms?

Your patient’s mental health assessment form contains sensitive and private information which you have a legal obligation to keep secure. While this may sound like a headache, Carepatron makes it incredibly easy to store, access, and edit all different medical records, including mental health assessment forms, in a HIPAA-compliant way.

With your data privacy covered, you can then start to look for ways to improve your practice’s administration and management, and we’ve got you covered there too. Send out automated SMS or email appointment reminders and reduce no-shows, sync your team’s calendars, improve your organization, manage billing and medical coding, utilize our smart voice-to-text transcription software, or offer your patients their own Carepatron client portal to book appointments with you and access their medical records securely.

As you can see, Carepatron has a whole suite of software solutions waiting for you, and you can even find this mental health assessment form, and hundreds of other handy, premade templates, within Carepatron’s community template library.

Mental Health Assessment Software
What are the different types of mental health assessments?
What are the different types of mental health assessments?

Commonly asked questions

What are the different types of mental health assessments?

Different mental health assessments may be used depending on the age of the patient. Adolescents and children will have a different mental health assessment than adults or the elderly, and their psychosocial histories may focus more on their early development whereas adults or the elderly will focus more on their vocational or educational history.

How do I conduct a mental health assessment?

A mental health assessment is, above everything, a conversation with your patient. Your clinical insights and observations during this conversation form important evidence that makes up the mental health assessment. To conduct a mental health assessment, therefore, you should be able to talk with your patient face-to-face in a sufficiently quiet and uninterrupted session to allow you to make important observations.

How often should a patient have a mental health assessment?

The answer to this question will depend on your patient’s progress, and if there are any significant changes or updates to their care. While you may only conduct a full mental health assessment on intake, components of the mental health assessment such as the risk assessment or mental health assessment may be conducted more frequently.

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