Mental Health Assessment Templates to Use in 2025

A complete mental health assessment consists of several key components, each contributing valuable insights:

1. Clinical Interviews: Essential for gathering information about the patient’s symptoms, medical history, and how their mental health impacts daily life.
2. Psychological Testing: Standardized tools like the Beck Depression Inventory and General Anxiety Disorder-7 (GAD-7) help measure symptom severity and track progression.
3. Observational Assessment: Observing behavior, speech, and interactions provides valuable insight, especially for conditions like mood disorders and autism.
4. Physical Health Evaluation: Helps rule out medical conditions that might mimic or exacerbate psychiatric symptoms.
5. Social and Environmental Factors: Factors such as family, work stress, and housing conditions impact mental well-being and should be considered in treatment planning.

To enhance the accuracy and consistency of mental health evaluations, several standardized tools are commonly used:

1. Beck Depression Inventory (BDI): A 21-item self-report questionnaire that assesses the severity of depression symptoms in adolescents and adults, covering aspects such as mood, pessimism, and loss of pleasure.
2. Geriatric Depression Scale (GDS): Specifically designed for older adults, the Geriatric Depression Scale is a brief questionnaire that helps identify depression in the elderly population, considering the unique presentation of depressive symptoms in this age group.
3. Patient Health Questionnaire-9 (PHQ-9): A brief, self-administered tool based on the DSM-IV criteria that assesses the severity of depression. Widely used in primary care settings, it is effective for tracking treatment progress.
4. SCOFF Questionnaire: A simple, five-question screening tool for eating disorders that can be easily administered in primary care settings to identify potential eating-related issues.
5. Dissociative Experiences Scale (DES): This 28-item questionnaire covers various dissociative symptoms, such as depersonalization and derealization, helping clinicians assess dissociative experiences in patients.
6. Life Events Checklist (LEC): A self-report measure that includes 17 items covering traumatic experiences, such as natural disasters, accidents, and interpersonal violence, to assess the impact of these events on mental health.
7. Mood Disorder Questionnaire (MDQ): A brief, self-report screening instrument for bipolar spectrum disorders that assesses symptoms of mania or hypomania, helping clinicians evaluate mood-related conditions.
8. Panic Disorder Severity Scale (PDSS): This tool evaluates various aspects of panic attacks, including frequency, distress, and impact on daily functioning, offering a comprehensive understanding of panic disorder severity.
9. DSM-5 Criteria: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides diagnostic criteria for a wide range of mental health conditions, ensuring diagnoses are consistent and evidence-based.

Each of these tools serves a unique purpose in mental health evaluations, providing both qualitative and quantitative insights that support accurate diagnosis and effective treatment planning.

Standardized templates can make the process of conducting mental health assessments more efficient and accurate. Here’s how they can support your practice:

• Increase Consistency and Accuracy: Templates ensure comprehensive data collection, reducing errors and omissions.
• Reduce Errors: Structured templates help avoid missed symptoms or contributing factors.
• Save Time: Pre-made templates save valuable time, allowing clinicians to focus on patient care.

Client Information:
– Name: John Doe
– Date of Birth: 02/15/1985
– Date of Assessment: 11/25/2024
– Clinician Name: Dr. Sarah Lee
– Contact Information: (555) 123-4567

Presenting Problem:
– Chief Complaint: John reports feeling “constantly down” and “unable to get excited about anything” for the past six months. He describes feeling overwhelmed at work and has trouble concentrating.
– Duration of Problem: Symptoms began approximately six months ago after a significant work project failed, and have been gradually worsening.
– Recent Stressors/Events: John recently experienced a breakup, and his workload at the office has increased significantly, causing heightened stress.

Mental Health History:
– Previous Mental Health Issues: John reports a history of mild depression in his early twenties, which resolved after a short period of therapy.
– Family History: Both of John’s parents have a history of depression.
– Substance Use History: Denies alcohol or drug use.
– Medications: Currently not on any psychiatric medications.

Current Symptoms (Rate on a scale of 1-10):
– Mood: 4/10 (Describes feeling sad most days, with occasional moments of happiness)
– Sleep Patterns: 6/10 (Reports difficulty falling asleep, waking up early)
– Appetite/Weight Changes: 5/10 (Decreased appetite; slight weight loss in the past month)
– Energy Level: 3/10 (Feels fatigued throughout the day, unable to concentrate)
– Thought Patterns: 6/10 (Has frequent thoughts of inadequacy at work and in personal life)
– Social Interactions: 4/10 (Has been avoiding social events; prefers staying home)
– Behavioral Changes: 5/10 (Increased irritability, especially with coworkers)

Mental Status Examination:
– Appearance: Well-groomed but slightly disheveled.
– Behavior: Restless, frequently shifts in seat.
– Speech: Normal speed, but somewhat flat in tone.
– Mood: Describes feeling “hopeless” and “stressed.”
– Affect: Restricted affect, limited emotional expression.
– Thought Process: Coherent but slightly preoccupied with work stress and personal issues.
– Cognition: Alert and oriented to person, place, and time.
– Insight and Judgment: Good, acknowledges his emotional struggles but is unsure about treatment options.

Assessment & Diagnosis:
– Summary of Findings: John is experiencing moderate symptoms of depression, exacerbated by work-related stress and a recent breakup.
– Diagnosis: Major Depressive Disorder (Moderate), Generalized Anxiety Disorder (Mild)

Treatment Plan:
Goals:
– Short-term: Improve sleep hygiene and reduce work-related stress.
– Long-term: Address negative thought patterns and manage depressive symptoms with therapy and medication.
– Interventions: Cognitive Behavioral Therapy (CBT) for depression and anxiety; consider SSRIs if symptoms do not improve.
– Follow-up: Schedule a follow-up appointment in two weeks to assess progress.

Client Information:
– Name: Maria Gonzales
– Age: 30
– Date: 11/25/2024

Mood Symptom Rating (Scale 1-10):
– Depressed Mood: 7/10 (Reports feeling sad for most of the day, nearly every day)
– Anxiety Level: 6/10 (Worries about job performance and future)
– Irritability: 5/10 (More irritable than usual, particularly with family members)
– Stress Level: 8/10 (Feels overwhelmed by responsibilities at home and work)
– Hopelessness: 6/10 (Feels like things won’t improve, but still hopeful for the future)
– Confidence Level: 4/10 (Struggles with self-esteem, feels inadequate at work)

Mood History:
– Frequency of Low Mood: Daily
– Duration of Low Mood: Has been experiencing depressive symptoms for the past four weeks.
– Triggers: Maria reports that the death of her father a month ago, along with increased pressure at work, triggered her low mood.

Coping Mechanisms:
– Healthy Coping Mechanisms: Practices yoga twice a week, and speaks with close friends for support.
– Unhealthy Coping Mechanisms: Uses social media excessively, and often engages in negative self-talk.

Action Plan:
– Immediate Actions: Recommend starting grief counseling for the loss of her father. Introduce mindfulness exercises to reduce anxiety.
– Long-term Strategies: Develop healthier coping strategies, including journaling and deeper engagement in physical activities. Discuss the potential for therapy to address self-esteem issues.

Client Information:
– Name: James Thompson
– Age: 45
– Date of Assessment: 11/25/2024

Depression Symptoms (Rate on a scale of 1-5):
– Loss of interest in activities: 4/5 (No longer enjoys hobbies, avoids social gatherings)
– Feeling down or depressed: 5/5 (Feels sad and uninterested in life, reports low energy)
– Trouble sleeping or sleeping too much: 3/5 (Frequently wakes up in the middle of the night)
– Fatigue or lack of energy: 5/5 (Feels exhausted by the end of the day)
– Feeling worthless or guilty: 4/5 (Has guilt over not spending enough time with family)

Anxiety Symptoms (Rate on a scale of 1-5):
– Excessive worry about different things: 4/5 (Worries about job performance and family responsibilities)
– Feeling restless or on edge: 3/5 (Feels easily overwhelmed by small tasks)
– Fatigue easily: 4/5 (Constantly fatigued, no matter how much he sleeps)
– Trouble relaxing or calming down: 4/5 (Difficulty unwinding after work, has trouble falling asleep)
– Difficulty concentrating: 3/5 (Has trouble focusing at work, often distracted)

Symptoms Frequency:
– Depressive Symptoms: Frequently, most days of the week.
– Anxiety Symptoms: Occasional, but worsening under stress.

Outcome:
– Severity Level: Moderate to severe for both depression and anxiety.
– Suggested Next Steps: Refer for CBT to address both anxiety and depression; consider starting an SSRI for depression and anxiety management.