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:
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