Psychology Lasa
Initial Assessment / Mental Status Check
Name of Client ________Julia________________________________________ Date____04/18/2013_________________
Appearance:
__Well groomed __Neat X_casual _X_Unkempt __Unclean __Inappropriate __Bizarre __Unusual
General Presentation:
X_cooperative __Guarded __Distractible _X_Agitated
Speech:
__Clear _X_Tone (loud/soft) _X_Rhythmic _poverty of Speech __Rapid __Slow __Stutter __Pressured __Slurred
Affect:
__Appropriate __Blunted _X_Melancholy __Restricted __Labile __Inappropriate __Flat
Mood:
__Even _X_Depressed/sad _X_Anxious __Irritable __Angry __Elevated __Euphoric/elated __Expansive __Passive __Pessimistic __Blunted
Orientation:
_11:00A.M_Time WATAGUA AND ASSOICIATES __Place Felecia McElyea__Person
Intelligence Level: x_High _average __Low __Retarded
Judgement:
_rational _X_Impaired __Immature _X_Impulsive
Insight:
__Emotional __Intellectual __Denial __Blames Others __Blames Self _X_Slight Awareness __X Acknowledges problem
Thought Content:
_X_Logical/Reality Based __Delusions __Obsessions __Tangential __Illogical __Loose Associations __Hallucinations __Ideas of reference/influence __Compulsions _X_Flight of Ideas __Circumstantial __Inhibited __Concrete _X_Abstract
Comments:
Client displays justification and other denial based thinking process. She also has persistent drug use, as well as _a history of criminal activities and prostitution. Multiple suicide attempts which shows me she is a high risk client. __
____________________________________________________________________________________________________________________________________________________________________________________________________
RISK STATUS CHECK
Violence/Abuse: (Domestic and Workplace, Child and Sexual)
Present Risk: ____None ____Low ____Moderate ___X_High
Current: ___________has had several
Name of Client ________Julia________________________________________ Date____04/18/2013_________________
Appearance:
__Well groomed __Neat X_casual _X_Unkempt __Unclean __Inappropriate __Bizarre __Unusual
General Presentation:
X_cooperative __Guarded __Distractible _X_Agitated
Speech:
__Clear _X_Tone (loud/soft) _X_Rhythmic _poverty of Speech __Rapid __Slow __Stutter __Pressured __Slurred
Affect:
__Appropriate __Blunted _X_Melancholy __Restricted __Labile __Inappropriate __Flat
Mood:
__Even _X_Depressed/sad _X_Anxious __Irritable __Angry __Elevated __Euphoric/elated __Expansive __Passive __Pessimistic __Blunted
Orientation:
_11:00A.M_Time WATAGUA AND ASSOICIATES __Place Felecia McElyea__Person
Intelligence Level: x_High _average __Low __Retarded
Judgement:
_rational _X_Impaired __Immature _X_Impulsive
Insight:
__Emotional __Intellectual __Denial __Blames Others __Blames Self _X_Slight Awareness __X Acknowledges problem
Thought Content:
_X_Logical/Reality Based __Delusions __Obsessions __Tangential __Illogical __Loose Associations __Hallucinations __Ideas of reference/influence __Compulsions _X_Flight of Ideas __Circumstantial __Inhibited __Concrete _X_Abstract
Comments:
Client displays justification and other denial based thinking process. She also has persistent drug use, as well as _a history of criminal activities and prostitution. Multiple suicide attempts which shows me she is a high risk client. __
____________________________________________________________________________________________________________________________________________________________________________________________________
RISK STATUS CHECK
Violence/Abuse: (Domestic and Workplace, Child and Sexual)
Present Risk: ____None ____Low ____Moderate ___X_High
Current: ___________has had several
References: Gerrig (). Psychology and Life [18] (VitalSource Bookshelf), Retrieved from http://digitalbookshelf.argosy.edu/books/0558302572/outline/18 Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8–19.