By Emily Hanlon
When it comes to mental health care, one of the most important tools a psychologist can have is a structured mental health examination. But what exactly is a mental health examination, when is it used, and how do you conduct one? In this guide, we’ll break it all down, and provide you with a free, easy-to-use Mental Health Examination Template that you can download and use in your practice right away.
👉 Looking for a quick way to structure your mental health exams? At this end of this article, download the free mental health examination template.
What is a Mental Health Examination?
A Mental Health Examination (MHE) or Mental Status Exam (MSE) is a structured assessment used by mental health professionals to evaluate an individual’s emotional, cognitive, and psychological functioning. Think of it as a "check-up" for mental well-being, much like a physical health check-up, but focused on thoughts, emotions, and behaviours. In this article, I will use the abbreviations MHE and MSE interchangeably.
This examination provides a comprehensive snapshot of a person's mental state at a specific point in time. It’s often used to support diagnosis, develop treatment plans, and track progress over time.
Key Components of a Mental Health Examination
A mental health examination typically covers these key areas:
Appearance and Behaviour: How the person looks, dresses, and behaves during the session.
Mood and Affect: The person’s emotional state and how it matches their outward demeanour.
Speech and Communication: Tone, volume, speed, and coherence of speech.
Thought Processes and Thought Content: Whether thoughts are logical, clear, or disorganised.
Perception: If there are hallucinations, delusions, or sensory distortions.
Cognition and Memory: Assessing concentration, memory, and cognitive skills.
Insight and Judgment: How well the individual understands their mental health challenges and their ability to make sound decisions.
When Are Mental Health Examinations Conducted?
Mental health examinations are used in a variety of clinical, educational, and community settings. Here are some of the most common scenarios:
Intake Assessments: When a person begins therapy or treatment for the first time, an MSE provides a starting point for ongoing care.
Diagnostic Support: For determining mental health conditions like anxiety, ADHD, PTSD, or psychosis.
Ongoing Monitoring: Used to track changes in mental health over time, especially for clients in ongoing treatment.
Crisis Situations: During mental health emergencies or hospital admissions, an MHE helps determine the level of risk or immediate need.
Educational Assessments: School psychologists use MSE to assess students for learning difficulties or behavioural challenges.
Who Conducts Mental Health Examinations?
Private psychologists: Like you! You’ll conduct these assessments to support diagnosis, treatment, and care planning.
School psychologists: MHEs help identify learning difficulties and behavioural concerns.
Psychiatrists: For formal diagnosis and medication reviews.
General practitioners (GPs): Often used in primary care to refer patients for mental health support.
Mental health nurses: Conduct them as part of emergency assessments in hospital settings.
The Purpose of a Mental Health Examination
Mental health examinations serve as a critical tool for mental health care. Here’s why they matter:
To Support Diagnosis: Provides insight into mental health disorders like depression, anxiety, or psychosis.
To Inform Treatment Plans: Helps tailor a plan specific to a person’s unique emotional and cognitive needs.
To Track Progress Over Time: Enables comparison of a person’s mental health state at different points in treatment.
To Identify Risk: Helps determine if a person is at risk of harm to themselves or others.
By having a clear, consistent approach to conducting an MHE, mental health professionals can ensure no important details are missed, and all relevant information is captured.
How to Conduct a Mental Health Examination (Step-by-Step Guide)
Conducting a mental health examination can feel overwhelming without a structure in place. Follow these steps to ensure a smooth, thorough assessment.
Step 1: Set the Stage
Create a Safe, Private Space: Choose a quiet, non-judgmental space where the client feels safe and comfortable.
Build Rapport: Warm introductions can reduce client anxiety and build trust. This makes clients feel more at ease when answering personal questions. Note: if you are a psychologist, you can work these questions into your initial interview.
Step 2: Use the Template to Cover Key Areas
Use this step-by-step guide, and follow along using the downloadable template for each section. Again, as you get used to conducting MSE’s, you can weave these questions and observations into your initial intake interviews.
1. Appearance and Behaviour
Are they well-groomed, disheveled, restless, or calm?
Do they appear anxious, agitated, or relaxed?
2. Mood and Affect
What is the client’s reported mood (happy, sad, angry, anxious, etc.)?
Is their emotional expression congruent with their reported mood?
3. Speech and Communication
Is their speech clear, fast, slow, loud, or quiet?
Do they appear confused, verbose, or unusually quiet?
4. Thought Processes and Content
Are thoughts logical, disorganised, or racing?
Are there any obsessive thoughts, delusions, or paranoia?
5. Perception
Are there hallucinations (seeing, hearing, or feeling things that aren't there)?
6. Cognition and Memory
Assess attention span, short-term memory, and the ability to recall recent events.
7. Insight and Judgment
Does the client understand their mental health condition?
Can they make sound decisions and understand the consequences of their actions?
Step 3: Document Everything
Use the downloadable Mental Health Examination Template to ensure all key areas are recorded accurately. Notes should be clear, objective, and free from bias.
Step 4: Plan Next Steps
Summarise Findings: Use the completed examination to create a summary of the client’s mental health status.
Plan the Next Steps: This might include a follow-up assessment, treatment referral, or care plan development.
Download Your Free Mental Health Examination Template:
Looking for a simple, printable template to streamline your mental health examinations? Download the ready-to-use Mental Health Examination Template now. It includes:
7 Key Categories for comprehensive assessment (appearance, mood, perception, etc.)
Clear, fill-in-the-blank format to save you time and effort.
Easy for new clinicians, students, or seasoned professionals who want to document examinations clearly.
A MSE is a vital tool for clinicians, counsellors, and psychologists. It helps you assess emotional, cognitive, and psychological functioning and plays a pivotal role in supporting diagnosis, treatment, and care planning.
By using the Mental Health Examination Template, you’ll be able to simplify your process, ensure nothing is missed, and maintain professional, clear documentation.
And if you would like more step-by-step guides, downloadable templates, or tailored supports, join us in The Clinicians Forum. You became a clinician to make a difference. Now, let’s make it easier to do what you love.
If you’ve ever conducted a mental health exam, I’d love to hear your experience.
What’s been the most useful part of the process?
Do you have any advice for others conducting mental health exams?
Drop your thoughts in the comments below! 💬
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