Dundalk MD Mental Health Assessment

For suboxone treatment, suboxone clinic, suboxone doctors, please contact our addiction specialist 443-559-8354

🧠 Clinical Mental Health Assessment Outline

1. Identifying Information

• Name:

• Age:

• Gender:

• Date of Evaluation:

• Referred by (if applicable):

2. Presenting Problem

• Onset (When did it start?):

• Duration and frequency:

• Triggers or patterns:

• Impact on daily life:

3. Mental Status Examination (MSE)

A snapshot of psychological functioning at the time of assessment:

Domain	Observations
Appearance	Grooming, hygiene, clothing
Behavior	Agitation, cooperation, eye contact
Speech	Rate, volume, coherence
Mood	Reported emotional state (e.g., sad, anxious)
Affect	Observed emotional expression (e.g., flat, congruent)
Thought Process	Logical, tangential, racing
Thought Content	Delusions, obsessions, suicidal/homicidal ideation
Perception	Hallucinations, distortions
Cognition	Attention, memory, orientation
Insight & Judgment	Awareness of condition and decision-making ability

4. Psychiatric History

• Previous diagnoses:

• Prior psychiatric hospitalizations:

• Previous or current therapy:

• Psychiatric medications (past and current):

5. Medical History

• Chronic conditions (e.g., diabetes, hypertension):

• Neurological issues:

• Substance use:

• Sleep issues:

6. Family Psychiatric History

• Any known mental illness or substance use disorders in family members?

7. Social History

• Relationship status:

• Family dynamics:

• Employment and education:

• Social support:

• Legal issues:

8. Risk Assessment

• Suicidal ideation:

• Homicidal ideation:

• Self-harm behavior:

• Access to means (e.g., weapons, pills):

• Protective factors (e.g., social support, religion):

9. Functional Assessment

• Activities of Daily Living (ADLs):

• Work/school functioning:

• Interpersonal functioning:

10. Provisional Diagnosis (if done by a clinician)

Based on DSM-5 or ICD-10 criteria.

11. Recommendations

• Therapy (CBT, DBT, psychodynamic, etc.)

• Medication evaluation

• Support groups

• Lifestyle changes (exercise, sleep hygiene, etc.)

✅ Next Steps

Would you like to:

• Fill this out interactively (I can guide you question by question)?

• Use a digital/printable version (PDF or Word)?

• Get screening tools (e.g., PHQ-9 for depression, GAD-7 for anxiety)?

For suboxone treatment, suboxone clinic, suboxone doctors, please contact our addiction specialist 443-559-8354