Form Mh 678 - Adult Short Assessment - Los Angeles County Page 3
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3MH 678
ADULT SHORT ASSESSMENT
Page 3 of 3
Revised 6/20/11
IX. Mental Status
Perceptual Disturbance
Thought Content Disturbance
General Description
Grooming & Hygiene:
Well Groomed
None Apparent
None Apparent
Average
Dirty
Odorous
Disheveled
Hallucinations:
Visual
Olfactory
Delusions:
Persecutory
Paranoid
Bizarre
Tactile
Auditory:
Command
Grandiose
Somatic
Religious
Eye Contact:
Normal for culture
Persecutory
Other
Nihilistic
Being Controlled
Little
Avoids
Erratic
Self-Perceptions:
Depersonalizations
Ideations:
Bizarre
Phobic
Suspicious
Motor Activity:
Calm
Restless
Ideas of Reference
Obsessive
Blames Others
Persecutory
Agitated
Tremors/Tics
Posturing
Rigid
Assaultive Ideas
Magical Thinking
Thought Process Disturbances
Retarded
Akathesis
E.P.S.
Irrational/Excessive Worry
None Apparent
Speech:
Unimpaired
Soft
Slowed
Sexual Preoccupation
Associations:
Unimpaired
Loose
Mute
Pressured
Loud
Excessive
Excessive/Inappropriate Religiosity
Tangential
Circumstantial
Slurred
Incoherent
Poverty of Content
Excessive/Inappropriate Guilt
Confabulous
Interactional Style:
Culturally congruent
Behavioral Disturbances:
None
Cooperative
Sensitive
Flight of Ideas
Word Salad
Aggressive
Guarded/Suspicious
Overly Dramatic
Concentration:
Intact
Impaired by:
Uncooperative
Demanding
Demeaning
Negative
Silly
Rumination
Thought Blocking
Orientation:
Oriented
Belligerent
Violent
Destructive
Clouding of Consciousness
Disoriented to:
Self-Destructive
Poor Impulse Control
Fragmented
Time
Place
Person
Situation
Excessive/Inappropriate Display of Anger
Abstractions:
Intact
Concrete
Intellectual Functioning:
Unimpaired
Manipulative
Antisocial
Judgments:
Intact
Impaired
Suicidal/Homicidal:
Denies
Ideation Only
Impaired re:
Minimum
Moderate
Memory:
Unimpaired
Threatening
Plan
Past Attempts
Severe
Impaired re:
Immediate
Remote
Recent
Passive:
Amotivational
Apathetic
Insight:
Adequate
Amnesia
Isolated
Withdrawn
Evasive
Impaired re:
Minimum
Moderate
Fund of Knowledge:
Average
Dependent
Severe
Below Average
Above Average
Other:
Disorganized
Bizarre
Serial 7’s:
Intact
Poor
Mood and Affect
Obsessive/compulsive
Ritualistic
Mood:
Euthymic
Dysphoric
Tearful
Excessive/Inappropriate Crying
Irritable
Lack of Pleasure
Comments on Mental Status:
Hopeless/Worthless
Anxious
Known Stressor
Unknown Stressor
Affect:
Appropriate
Labile
Expansive
Constricted
Blunted
Flat
Sad
Worries
X. Summary
Summary/ Clinical Impression (including strengths and attitude towards treatment):
Diagnosis:
Axis I
Prim
Sec
Code __________
Nomenclature ______________________________________________
Sec
Code __________
Nomenclature ______________________________________________
Sec
Code __________
Nomenclature ______________________________________________
Axis II
Prim
Sec
Code __________
Nomenclature ______________________________________________
Sec
Code __________
Nomenclature ______________________________________________
Axis III
Code __________
Nomenclature ______________________________________________
Code __________
Nomenclature ______________________________________________
Code __________
Nomenclature ______________________________________________
Axis IV
1.
Primary support group
2.
Social environment
3.
Educational
4.
Occupational
5.
Housing
6.
Economics
7.
Access to health care 8.
Interaction w/legal system
9.
Other psychosocial/environmental
10.
Inadequate information
Axis V
GAF ________
Dual Diagnosis Code: _______________
Disposition/Recommendations/Plan:
____________________________________ __________
________________________________ __________
Signature & Discipline
Date
Co-Signature & Discipline (if required)
Date
Name:
IS#:
This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code,
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
Agency:
Provider #:
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of
Los Angeles County – Department of Mental Health
this information is required after the stated purpose of the original request is fulfilled.
ADULT SHORT ASSESSMENT
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