Mental Health Assessment Template with Examples

Mental Health Assessment Template

A mental health assessment template is a structured tool used by mental health practitioners to evaluate patients and develop treatment plans accordingly. It is used in therapy sessions at clinics or hospitals to identify underlying issues and track a patient’s progress over time. Using Heidi to complete mental health assessment templates will allow you to:

• Ensure that the patient’s mood, cognition, and behavior, among other mental health key aspects, are thoroughly assessed
• Use accurately and thoroughly collected data to develop tailored therapy strategies
• Keep organized and detailed records of patient assessments that comply with regulatory standards

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What is a Mental Health Assessment Template?

A mental health assessment template is a structured tool used to diagnose and monitor the progress of a mental health patient’s condition. The mental health assessment format depends on various factors like practice requirements and regional guidance, among others. 

Generally, mental health assessment templates should address a patient’s reason for a visit, presenting issue, past psychiatric history, current medication, mental status examination, diagnosis, treatment plan, safety assessment, and what further steps to take.

In this article, we’ll discuss the importance of using mental health templates, a brief history of these templates, and how mental health professionals can write detailed assessment reports without sacrificing accuracy.

The Importance of a Complete Mental Health Assessment Template

Clinicians must use a comprehensive mental health assessment template to prevent or minimize the risk of misdiagnosis. One particular case is that of a 23-year-old with bipolar disorder being misdiagnosed with major depressive disorder, and the fact that such cases are also commonly misdiagnosed.

Standardizing the assessment process using complete templates will allow professional caregivers to assess signs of mental illness accurately and reliably. This will reduce and prevent misdiagnosis as the report will include detailed information on past psychiatric history to discern incorrect diagnoses and track previous treatments more easily.

Evolution of the Mental Health Assessment Template

The concept of assessing mental health has come a long way since it began with mental hygiene, introduced by William Sweetzer and later expanded as a community-based approach by Dr. J. B. Gray. While the intentions were clear, early mental health assessments lacked consistency and reliability. Here’s how they’ve evolved over the years, leading to the evidence-based approaches used in clinical practice today.

Medical 203 as the Origin of Mental Health Assessments

Isaac Ray, founder of the American Psychological Association (APA), defined mental hygiene as "the art of preserving the mind against all incidents and influences calculated to deteriorate its qualities, impair its energies, or derange its movements.” His vision helped shape a growing consensus that mental health required structured attention, not just reactive care, which eventually led to the creation of Medical 203 after World War 2.

In 1952, Medical 203 was adapted for use in the civilian world in the form of the Diagnostic and Statistical Manual of Mental Disorders or DSM-I  by the APA. DSMs led to an 800% increase in the number of psychiatric diagnoses. It also served as a standardized criteria for diagnosing mental health conditions and laid the groundwork for consistent assessment templates.

Standardized Criteria: Early DSMs

DSM-I introduced a classification system encompassing 106 mental disorders, broadly categorized into these 5 groups:

• Psychotic disorder
• Neurotic disorder
• Personality disorder
• Psychophysiologic autonomic and visceral disorders
• Mental deficiency

In 1968, the APA published DSM-II which expanded to 182 disorders with more distinct categories and also included childhood disorders.

DSM-III was introduced in 1980 and allowed a more comprehensive assessment using a multi-axial system. The system intends to offer a standard and organized way of sifting through a patient’s diagnostic information using different axes.

Evidence-Based and Multidimensional Assessments

The DSM-IV was published in 1994, and the DSM-IV-TR text revision in 2000 continued to use the DSM-III multiaxial system. This aimed to enhance diagnostic precision using empirical research. Structured clinical interviews like the SCID, first used alongside DSM-III complemented DSM-IV’s diagnostic criteria to systematically assess major mental health disorders.

While the DSM-IV introduced a framework to consider cultural factors in diagnoses, the CFI advanced the emphasis on cultural understanding. The CFI is a set of semi-structured questions meant to help assess cultural influences which improves culturally sensitive diagnosis and treatment.

Personalized and Dimensional Approaches: DSM-5 Era

The DSM-5, published in 2013 and revised in 2022 into the DSM-5-TR, deleted numerous disorder subtypes that confused clinicians and caused overlaps in diagnoses while also removing the multi-axial system. Integrating medical disorders, psychological factors, and mental disorders into a single framework streamlined mental health assessments..

The key features of DSM-5 include diagnostic classification, diagnostic criteria sets, descriptive text, introduction of new disorders, revisions on terminology and criteria, cultural considerations, and better alignment with the International Statistical Classification of Diseases and Related Health Problems (ICD).

The revision incorporates updated research and clinical findings as well as including revised criteria sets, updated diagnostic codes, and the latest understanding of mental disorders. This is still in active use today.

Future Direction: Use of AI in Mental Health Assessments

In addition to the continuous use of DSM-5, clinicians have also begun using AI and machine learning to analyze data sources to allow for early detection. A study was also launched to see whether analyzing a patient’s social media history will be effective in detecting mental health issues early on. This introduced concerns of invasiveness and privacy issues.

A non-invasive approach to using AI involves using AI-powered medical scribes to handle the documentation of an assessment. AI medical scribes like Heidi are used extensively today in empowering clinicians to improve patient care.

Dr. Dimitriy Chernov of West Hertfordshire Teaching Hospitals conducted an independent evaluation of Heidi Health’s AI medical scribe by examining 100 patient encounters. This resulted in an 85% reduction in documentation time by turning six minutes of note-taking to about a minute per patient.

As Heidi focuses on note-taking using customizable templates, this result can also translate to mental health assessments. Watch the video below to see Heidi in action:

Easy Steps to Create a Mental Health Assessment Template with Examples

Creating a mental health assessment template ensures a structured and comprehensive approach to evaluating and managing a patient’s mental health concerns. Below are the key sections to include, along with example content based on a typical assessment.

1. Patient Information

• Name: Jane Smith
• Date of Birth: 07/12/1990
• Date of Consultation: 03/15/2024
• Medical Record Number: 789012

2. Reason for Visit

• Assessment and Management of Mental Health Concerns: Anxiety and Stress Management

3. Presenting Issue

• Symptoms: Frequent worry, restlessness, difficulty concentrating, muscle tension
• Duration: Symptoms present for the past 8 months
• Impact on Daily Life: Difficulty at work, strained personal relationships, trouble sleeping

4. Past Psychiatric History

• Previous Diagnoses: Generalized Anxiety Disorder
• Previous Treatments: Cognitive Behavioral Therapy (CBT), occasional use of benzodiazepines
• Hospitalisations: No previous psychiatric hospitalisations

5. Current Medications

• Medication Name: Escitalopram 10 mg daily
• Adherence: Good adherence
• Side Effects: Occasional mild headaches

6. Mental Status Examination (MSE)

• Appearance: Well-groomed, appropriate attire
• Behavior: Cooperative, slightly fidgety
• Speech: Normal rate and volume
• Mood: Anxious
• Affect: Congruent with mood, mildly restricted
• Thought Process: Logical, coherent
• Thought Content: No delusions, no hallucinations
• Cognition: Alert, oriented to time, place, and person
• Insight: Good understanding of condition
• Judgment: Appropriate for situation

7. Assessment

• Diagnosis/Working Diagnosis: Generalized Anxiety Disorder (GAD)
• Severity: Moderate symptoms, affecting daily functioning

8. Treatment Plan

• Medications: Continue Escitalopram 10 mg, consider dose adjustment if symptoms persist
• Therapy: Recommend Cognitive Behavioral Therapy (CBT), referral to a therapist
• Lifestyle Modifications: Encourage mindfulness techniques, regular physical activity, improved sleep hygiene
• Follow-Up: Schedule follow-up appointment in 6 weeks to monitor progress

9. Safety Assessment

• Suicide Risk: No current suicidal ideation or plan
• Self-Harm Risk: No current self-harming behaviors

10. Patient and Family Support

• Support Systems: Discussed support from family and friends, involvement in treatment
• Emergency Contacts: Provided information for emergency mental health services

11. Next Steps

• Follow-Up Appointment: Scheduled for 04/26/2024
• Referrals: Referral to a psychologist for CBT
• Additional Testing: No additional tests required at this time

12. Signature and Contact Information

• Practitioner Name: Dr. Emily Carter
• Designation: Psychiatrist
• Contact Number: 555-987-6543
• Date: 03/15/2024

Mental Health Assessment Template Example

Our Template Community also contains multiple field-tested templates, including ones created by actual mental health professionals for other mental health professionals.

Mental Health Assessments Made Easier with Heidi

While following the template itself is fairly simple, lengthy consults can drone on and keep a clinician from effectively keeping track of all the details talked about. Streamlining the process by using Heidi to transcribe all relevant information and fill out a set template.

• Transcribe – After securing consent from the patient, use your computer or mobile device and press “Start transcribing.” When adopting the scribe for the first time, you can upload your own notes or recording to generate a new assessment according to a particular template.
• Customize –  Select or tell Heidi to use a specific template to generate an assessment of the patient. Heidi will auto-populate the medical health assessment template to produce a complete report.
• Transform – Review the assessment to validate the information captured during the consult. Should there be new DSM updates, you can modify your existing template to include or exclude certain information to seamlessly stay up-to-date with assessments.

Heidi is an APPs and NZ IPPs-compliant AI scribe that actively handles more than 1 million patient consults across over 50 countries, while remaining compliant with other regulations like HIPAA and GDPR.

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Free Mental Health Assessment Template Samples

Community Mental Health Needs Template

A community mental health needs assessment template is structured to systemically gather and analyze data on a specific community’s mental health needs. This template is used by government agencies, community groups, and healthcare organizations to develop strategies to improve the community’s mental health care.

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Comprehensive Mental Health Assessment Template

This mental health assessment template is a structured document that evaluates an individual’s mental health state. This delves into the patient’s psychological, emotional, and behavioral conditions, current medications, medical history, safety assessment, and any appropriate treatment plans. This enables thorough documentation on depression and anxiety.

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Child Mental Health Assessment

This mental health assessment template is specifically designed for pediatricians to document a comprehensive assessment of young patients. This covers a child’s progress at home and school, current mood, sleep and dietary patterns, and any medication side effects. This helps introduce early intervention to any conditions a child might have.

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FAQs About Mental Health Assessment Templates

What are the 5 Ps in mental health assessment templates?

The 5 Ps in mental health assessment templates are the Presenting problem, Predisposing factors, Precipitating factors, Perpetuating factors, and Protective factors. This model tackles what problem a patient is seeking support with, what prompted them to seek support, what’s keeping the problem going, what makes the patient more susceptible to the problem, and what their strengths are to manage it.

What are the 5 Cs of mental health assessment templates?

There is no universal framework for the 5 Cs in mental health assessments but could mean Connection, Compassion, Coping, Community, and Care. This refers to relationships, understanding others and themselves, mechanisms to maintain mental health, becoming part of a social network, and seeking professional help. An additional possible meaning is Competence, Confidence, Character, Connection, and Care.

How can I create my own mental health assessment templates?

You can create your own mental health assessment template by either creating one from scratch or modifying an existing one from the Template Community. Heidi allows you to tailor an existing template by asking it to include or exclude certain information in the assessment and even share it with the community. You can review our guide for creating custom templates.