CFDFL Brief Mental Status Exam Template - NIATx

THE CENTER FOR DRUG-FREE LIVING, INC.Brief Behavioral Health Status Exam ( 1091 )CLIENT NAME:Start Time:End Time:NUMBER:Purpose of Exam: Evaluate Clinical Necessity Evaluate Service NeedsSetting: Residential Outpatient Detox Other:APPEARANCE: Clean Neat Unkempt Disheveled Other:Looks Stated Age: Yes No Younger OlderEYE CONTACT: Appropriate InappropriateORIENTATION: X 4: Time Place Person SituationMEMORY: Normal Limits Deficient: Immediate Recent RemoteOther:ATTENTION: Adequate InadequatePERCEPTION: Adequate InadequateMOTOR ACTIVITY: Normal Slowed Restless AgitatedCOGNITIVE PERFORMANCE: Normal Limits Poor memory Low self-awarenessShort attention Developmental disabilityPoor concentration Impaired judgementSlow processingTHOUGHT PROCESS: Normal limits Illogical DelusionalHallucinating (visual, auditory, tactile)Paranoid Ruminative Intact Derailed thinkingLoose associationAnti-psychotic medicationDANGER TO OTHERS: Does not appear dangerous to others Violent temperThreatens others Physical abuser Hostile AssaultiveHomicidal ideation Homicidal threats Homicide attemptDANGER TO SELF: Does not appear dangerous to self Suicidal ideationCurrent plan/means Recent attempt Past attemptSelf-injurySelf-mutilationSENSORY DEFICITS: None or Speech Hearing Vision

THE CENTER FOR DRUG-FREE LIVING, INC.Brief Behavioral Health Status Exam ( 1091 ) ContinuedCLIENT NAME:NUMBER:SPEECH: Clear Slurring Slowed Loud Soft Pressured ExcessiveMinimal Incoherent Other:MOOD: Euthymic Unremarkable Depressed Tearful Anxious ManicLabile Other:AFFECT: Full range Constricted range FlatINSIGHT INTO PROBLEM: Takes responsibility Intellectual insight Emotional insightSlight awareness Blames others Complete denialBEHAVIOR DURING INTERVIEW: Cooperative Guarded Withdrawn Acting OutOppositional Hostile PassiveOther:ADDITIONAL OBSERVATIONS:CLIENT STRENGTHS:SERVICE NEEDS:PROVISIONAL IMPRESSION/DIAGNOSIS:303.90 Alcohol Dependence-311.00 Depressive Disorder NOSPLAN OF TREATMENT: Individual Therapy Group TherapyFamily TherapyPsychiatric ReferralDISCHARGE CRITERIA:Clinician Signature: ____________________________________________ Date: _________If Medicaid client: LPHA, M. CAP Signature: ________________________Date: _________Revised 3/05 HRB