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1 Southern Light Counseling CD Vendor# SLC NPI# Mental Status Exam Property of SLC Copying without permission is prohibited Client: SSN#: Pay Source: Legal Guardian: Relationship to Client: N/A SLC Admission Date: Southern Light Counseling Home Court Advantage : H.C. Case Manager: Referred by: Self CD Worker/Name/Creds/Agency: RST EAP Other Date of Service: Start Time: End time: Place of Service: 11 In Office 12 In Home 14 Residential Other: Units of Service Provided: Appearance Appears to be chronological age Weight proportionate to height Clothing and accessories appropriate to culture and situation Apparent nicotine stains Dental erosion Rash around mouth Needle/track marks ticeable body odor Body modifications Other Attitude/Rapport Excellent Good Fair Poor Mood (self report) Angry Anxious Indifferent Other Behavior Eye contact Repeatedly glances to one side Avoids making eye contact Good quality eye contact Other Body Movements (observed) abnormal body movements Tremor Abnormal gait Hyper activity Tic Other
2 Mood/Affect Appropriate to situation Congruent /in congruent with thought and mood Thought Process Quality of Ideas Frequent and spontaneous introduction of new viable ideas in course of conversation Intensity rmal Blunted Exaggerated A free flow of new viable ideas A few new viable ideas presented in course of conversation Return to same limited set of ideas Range of Emotional Expression Constricted Fixed Mobile Liable Changed affect flexibility and appropriately with flow of conversation Speech/(Production of speech) Para linguistic features Pressured Rapid Prolonged Latent Spontaneous Soft Loud Specific language disorders Stuttering Difficult to understand Difficult to understand Repeats words of others (echolalia) Pragmatic Aspects of speech Repeats own words (palilalia) Mutism Makes up words with specific meaning To Self (neologism) Other Tempo Flight of ideas noted by incoherent speech Form Slow thought processing and few associations Thoughts keep pace with conversation Speech interrupted by silences (blocking) Off the point responses (derailment) Deviates from topic of discussion (tangentially) Invalid reasoning (illogical) Other Thought Content Over valued ideas Client holds false belief with conviction that: Over weight Ill A body part is abnormal Other Obsessions Client unable to suppress undesired, unpleasant, intrusive thought Other Phobias Client dreads a harmless object or situation Other 2
3 Thought Content Preoccupations Suicidal Ideation Homicidal Ideation Unfounded suspicions Cognitive distortions producing anxiety/depression Delusions General mistrust of others beliefs of conspiracy (paranoid) Assigns personal significance to mere coincidences (reference) Fantastical beliefs that self is famous, powerful, etc (grandiose) Belief that a famous person is enamored with him/her and is sending confirmations of love (telepathically or otherwise) (erotomanic) Belief that the identity of a person, object, or place has somehow changed or been altered (misidentification) Belief that thoughts have been taken out of the client s mind and he/she has no control over it (thought withdrawal) (controlled thought) Feeling that thoughts are not his/her own (thought insertion) (controlled thought) Belief that others can hear his/her thoughts (broadcasting) False self accusation (guilt) False belief he/she is financially incapacitated (poverty) Belief he/she has no mind or is dead (nihilistic) Perceptions Client experiences a sensory perception as real in external or objective space in the absence of any external stimulus (hallucination) Client experiences a distortion of sensory experience and may recognize it as a false perception (illusion) Client experiences hallucinations in internal or subjective space - voices in head (pseudo hallucination) Client experiences time distortion (de ja vu) Client experiences a distorted sense of self (depersonalization) Client experiences a distorted sense of reality (de-realization) 3
4 Insight Client recognizes/understands own problem Client is compliant with Tx Other Judgment Client can make sound, reasonable, responsible, decisions Client is: Impulsive Socially aware Intellectual functioning (estimated) Intelligence Quotient (I.Q.) Above 70 Below 70 Adaptive functioning Adequate level of functioning Limitations impair level of functioning Self aware Has ability to plan Cognition (Refer to Mini-Mental Sate Exam Attachment) Client is: (alertness) Alert Aware Responsive to the environment Client is oriented to: (oriented) Person Place Time Client can focus on a specific stimulus, while ignoring other stimuli (attention and concentration) Client can remember specific information : (memory) Immediate registration (registration MMSE) Short term (recall MMSE) Long term (orientation - MMSE) Cognition (Refer to Mini-Mental Sate Exam Attachment Client s minds eye correctly visualizes, recalls and learns information (visual spatial functioning) Client can name objects, repeat phrases and spontaneously respond to instructions (language- MMSE) Client can manage, regulate, control, cognitive processes (executive function) 4
5 Cultural Considerations Client s race White/Caucasian Black/African American Hispanic Asian Native American Other Client presents self in keeping with cultural background Clinician Day Date Reviewed by Date Clinical Supervision Utilization Review Reviewed by Date Clinical Supervision Utilization Review ed to: Date 5
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Dean Hope Center for Educational and Psychological Services Teachers College, Columbia University Box 91, 525 West 120 th. Street, New York, N.Y. 10027-6696 Tel. (212) 678-3262 Fax. (212) 678-8105 Dinelia
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