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Intake Assessment Template: Case of __________ Intake Date: Instruction:

December 6, 2024

Intake Assessment Template: Case of __________

Intake Date:

Instruction: Respond to each applicable element (below). Use complete sentences and explain or describe accurately.

Identifying/demographic data:

Chief complaint/presenting problem:

History of present illness:

Past psychiatric history (evaluate any past diagnosis):

Substance use history:

Past medical history:

Family history (including medical and psychiatric):

Current family issues and dynamics (if available):

Mental Status Exam

Instruction: Be sure to address all nine elements below, which are the main components of the mental status exam. Respond to each using complete sentences. Explain or describe accurately.

Appearance:

Behavior or psychomotor activity:

Attitudes toward the interviewer or examiner:

Affect and mood:

Speech and thought:

Perceptual disturbances:

Orientation and consciousness:

Memory and intelligence:

Reliability, judgment, and insight:

>Biology homework help

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