A mental health assessment consists of a set of information regarding a client's present and past mental health and substance abuse problems, medical problems, social and family interactions. To understand how to write a mental health assessment (also called a psychiatric assessment or psychosocial assessment) you must first interview a client and write down the information by filling out an assessment form. The full assessment will be used to develop a care plan to improve or eliminate the client's current problem.
Steps
Step 1. Interview the customer
- During the interview with the client, you will collect all the information that will be part of the mental health assessment. In many mental health facilities, the practitioner completes an assessment form during the interview.
- Ask open-ended questions about the customer's problem and history.
- Look at the client's body language. Write down any behavior that seems out of the ordinary to you.
Step 2. Write your mental health assessment using the assessment tools or forms provided by your facility
The evaluation should include the following sections.
- Personal data: name, date of birth, gender, home address and telephone numbers.
- Symptoms: the ailments the client suffers from, such as depression, anxiety, insomnia, hallucinations, drug abuse, etc.
- Mental Health Clinical History: Past diagnosis and treatment for all mental health problems the client is accused of. This section should include the dates of diagnoses and treatments and whether the client felt they would benefit from the therapy. Make a note of any psychiatric drugs the client is currently taking.
- History of drug abuse: past and present alcohol and drug use. Specify the type of drug used, the method and the frequency of use. Also take note of any legal issues arising from using illegal drugs or driving under the influence of drugs.
- Clinical history: major surgeries, head injuries, chronic illnesses and incidents of significant importance. Also include your current medications (both prescription and over-the-counter medications).
- Socio-economic history: the client's financial condition and employment situation, information on family, marital status, sexual orientation, close relatives, religious and cultural background, criminal record, and any other personal information that can help understand the client's problem.
- Mental State Exam: Your observations about the client's mood, body language, behavior, and presentation. Include the following information: description of the customer's appearance (level of cleanliness, clothing, hygiene, and any visible physical anomalies); behavior (agitated, restless, on the verge of tears, or in a strange manner); mood (happy, hopeful, sad, depressed); effect (anxious, expressionless, angry or hyper excited); use of speech (normal, talkative, fast, slow).
- Client Strengths and Weaknesses: Client strengths can be their desire to work on the current problem and having a good support network behind them. Weaknesses can include past mental problems or a financial situation that can make it difficult to complete treatment.
- Narrative summary: it is a written interpretation of the information gathered and how the various elements may have contributed to the development of the current problem.
Step 3. Finish the evaluation with suggestions on possible therapies
Your treatment program will include a complete diagnosis according to the most commonly used diagnostic manuals. Include a diagnosis for each axis:
Step 4. Axis I:
main problem (such as major depressive disorder or bipolar disorder).
Step 5. Axis II:
personality disorder (such as borderline personality disorder) or mental retardation.
Step 6. Axis III:
medical problems (can only be diagnosed by doctors).
Step 7. Axis IV:
psychological and environmental problems.
Step 8. V axis:
Global Functioning Rating (GAF), a numerical grade on a scale from 0 to 100 that indicates the client's current ability to "function" with the stressors present in their life. A GAF score of 91 to 100 indicates that the client is able to "function" well and manage the stressors in their life. A GAF score of 1 to 10 indicates that the client is a danger to himself and / or others.
