Mental Status Exam & Risk Assessment (Behavioral Health)

Date/Time: [Date and time of assessment]

Setting: [outpatient / ED / inpatient / telehealth / community]

Clinician: [Name, credentials]

Reason for Assessment: [Precipitating reason for focused risk note] (One line stating why this risk-focused note is required, e.g., positive PHQ-9 item 9, patient disclosure, recent attempt, collateral concern.)

(This is a focused risk-specific documentation template, not a full psychiatric evaluation. Clearly distinguish observed findings from patient-reported experiences. Do not infer or assume negatives such as "denies SI/HI" or "no access to means" unless explicitly assessed and documented. If key elements cannot be determined, state "Not assessed" with reason and plan to reassess. Omit optional sections when not applicable. Document access to lethal means whenever any suicide or self-harm risk is present.)

Sources and Reliability

Information Sources: [Sources used] (List all: patient interview, direct observation, chart review, collateral contacts with name/relationship and consent status.)

Reliability and Limitations: [Overall reliability statement] (Note any limiting factors: intoxication, psychosis, guardedness, language barrier, cognitive impairment. Describe mitigation steps taken. If key risk elements could not be assessed, document reason and plan/timing to reassess.)

Current Safety Status

(Include this section only if special monitoring/containment, environmental safety measures, or legal/administrative status are in place. Omit if none apply.)

• Current Monitoring: [Monitoring/containment measures in place] (e.g., 1:1 observation, line-of-sight, family supervision, none)
• Legal/Administrative Status: [Voluntary / involuntary hold / other]
• Environmental Safety Actions: [Concrete actions completed] (e.g., removal of sharps/medications/ligatures, room cleared, belongings secured)

Mental Status Examination

(Use brief, structured phrases. Attribute content as observed versus patient-reported. Do not default to "within normal limits" without examination. If not assessed, write "Not assessed" or omit the domain.)

• Appearance and Behavior: [Apparent age, grooming, attire, risk-relevant physical findings such as visible injuries or scars]; [Attitude: cooperative / guarded / hostile / other]; [Eye contact: adequate / limited / avoidant]
• Motor Activity: [Psychomotor status: normal / agitation / retardation / tremor / abnormal movements]; [Alertness and attention]
• Speech: [Rate: normal / rapid / pressured / slowed]; [Volume: normal / loud / soft]; [Prosody: normal / monotone]; [Latency]
• Mood (patient-reported): [Patient-stated mood, using their words when clinically informative]
• Affect (observed): [Range: full / constricted / blunted / flat]; [Intensity]; [Stability: stable / labile]; [Congruence with stated mood and content]
• Thought Process: [Linear and goal-directed / circumstantial / tangential / loose associations / flight of ideas / thought blocking] (If disorganized, note impact on safety planning ability.)
• Thought Content: [Pertinent findings: SI, HI, self-harm urges, delusions with themes, paranoia, obsessions, guilt/shame] (Detail SI/HI/NSSI specifics in Risk Assessment sections.)
• Perceptions: [Hallucinations by modality; command hallucinations with content and intent-to-act; dissociative symptoms] (Document absence as pertinent negative when evaluating for psychosis.)
• Cognition: [Orientation; attention] (Brief assessment sufficient for safety and capacity decisions. Use developmentally appropriate descriptors for youth or intellectual disability.)
• Insight and Judgment: [Insight into symptoms and need for treatment]; [Judgment regarding safe decision-making and ability to follow safety plan]; [Impulse control with behavioral anchors]

Suicide and Self-Harm Risk Assessment

(Provide a structured, time-anchored clinical narrative supporting risk level determination.)

Suicide Inquiry:

• Ideation: [Presence/absence with time anchoring: today, past 48 hours, past month, lifetime] (Specify passive death wish versus active ideation; frequency, intensity, duration.)
• Plan: [Method, specificity, timing, location, preparatory steps] (If not assessed, state reason and plan to reassess.)
• Intent: [Desire to die, expectation of acting, perceived lethality, deterrents, ambivalence]
• Recent Suicidal Behavior: [Attempts, aborted attempts, rehearsals with date, method, medical severity, and stated intent at time]

Non-Suicidal Self-Injury: (Include if applicable.)

• [Methods, frequency, medical severity]
• [Triggers and function: emotion regulation / dissociation / self-punishment / other] (Clarify distinction from suicidal self-directed violence.)
• [Escalation pattern over time]

Access to Lethal Means: (Required when any suicide or self-harm risk is present.)

• Firearms: [Presence, access, storage: locked/unlocked, loaded/unloaded; who controls access; plan to restrict]
• Medications: [High-risk medications available, quantities, stockpiling behavior; secure storage plan]
• Other Means: [Ligatures, sharps, heights, vehicles, chemicals as relevant]
• For Minors/Dependent Adults: [Caregiver control, supervision level, willingness to restrict] (Include when applicable.)

Risk Factors:

• Acute Drivers: [Recent stressors, intoxication/withdrawal, agitation, insomnia, command hallucinations, access changes]
• Chronic Vulnerabilities: [Prior attempts, chronic mental illness, trauma history, family history]
• Escalation Patterns: [Worsening ideation/behavior, increased planning/preparation]

Protective Factors: (Document concretely, not generically.)

• [Reasons for living in patient's words]
• [Specific social supports and willingness to use them]
• [Therapeutic engagement and adherence]
• [Responsibilities, cultural/religious beliefs, future-oriented plans, effective coping strategies]

Risk Formulation: [Narrative synthesis explaining why risk is elevated now versus baseline, primary drivers, balance of acute/chronic risk, and how data supports conclusions] (3–6 sentences. Explicitly state if protective factors are insufficient to mitigate acute risk.)

Risk Level: [low / moderate / high / acute elevated / chronic baseline] (Use organizational terminology. State 3–5 decisive factors supporting this level. Note foreseeable changes that would increase risk.)

Violence and Homicide Risk Assessment

(Include only when violent ideation, threats, or credible concern for aggression toward others is present.)

Current Ideation: [Presence/absence with time frame; specific target(s); access to target; plan; intent; triggers; associated symptoms: paranoia, command hallucinations, manic irritability, intoxication]

History and Context: [Prior violence or threats, domestic violence, weapons offenses, recent escalation, stalking, substance-linked aggression]

Weapon Access: [Firearms and other weapons; storage; carrying; recent acquisition or changes]

Protective Factors: [Commitment to nonviolence, supportive relationships, separation from target, legal constraints, engagement in care]

Violence Risk Formulation and Level: [Statement of immediacy and credibility with assigned risk level and key supporting reasons]

Immediate Mitigation Actions

Safety Plan: [created / reviewed / updated / unable to complete / declined] (If completed, summarize: warning signs identified, internal coping strategies, social supports with contact info, crisis resources provided, environment safety steps agreed. For youth, include caregiver supervision plan. If declined/unable, document reason and alternative actions.)

Means Counseling and Restriction: [Counseling provided, what was agreed and by whom, verification method] (If no action taken, document why and what was offered.)

Clinical Escalation: [Increased monitoring, ED referral, involuntary evaluation, inpatient/crisis admission, crisis team activation, acute medication interventions with monitoring plan] (Include if applicable.)

Follow-up Plan: [Specific date/interval, modality, responsible clinician/service; warm handoff details; between-visit contact plan if arranged]

Notifications and Mandatory Reporting

(Include only if applicable: duty to protect/warn, credible threat notifications, abuse/neglect reporting, or other confidentiality exceptions.)

Nature of Concern: [Trigger for notification and indicators of seriousness/imminence]

Recipients: [Law enforcement / crisis team / receiving facility / identified target / APS/CPS / guardian / supervisor / risk management]

Information Disclosed: [High-level summary adhering to minimum necessary standard]

Patient Notification: [Whether patient was informed of disclosure; if not, clinical rationale]

Disposition

Final Disposition: [outpatient with safety plan / ED transfer / inpatient admission / crisis stabilization / other]

Clinical Rationale: [Brief statement connecting risk formulation to disposition and feasibility of outpatient safety] (If patient left against advice, document capacity assessment, risks explained, alternatives offered, and safety actions taken.)