Brief Status Exam: Fill & Download for Free

Demographics and family information followed by why the individual is presenting for treatment. A brief family history and presenting symptoms and past treatment.A brief summary of medical history. A summary of any psychological testing. A mental status exam if included. Referral information, including the name of the referring professional and whether they are requesting follow up information.Psychiatric evaluation attached to report with a brief summary and history of medications and psychiatric hospitalization. Diagnostic impressions, Treatment recommendations. Further information may be added as needed. Treatment notes, preliminary discharge, discharge notes, physician notes if any and discharge follow. Recommendations for family therapy, after care and any further follow up as required.

So, starting with a little pedantry. Psychiatrists are medical doctors. They may use brief assessment tools, which are not difficult to lie on, and/or a procedure known as a mental status exam, but they don't typically conduct what I would call a psych evaluation. These are conducted by a psychologist with a Ph.D. and specific training, and would involve some combination of formal assessments ("psychological testing"), mental status exam, and interview, and usually involves two or more hours of client content, as well as, potentially, interviews with family members and/or other providers. Many formal assessments are actually designed in such a way to make it very difficult to deceive them--there are certain items or questions that, if answered in certain ways, raise red flags about the truthfulness of other responses. Obviously they are not fool-proof, however combined with the interview, they would typically be very reliable. There are also other types of evaluations that can be performed by other mental health providers. The quality and accuracy of any assessment will vary based on the skill of the provider and the time they have to complete the assessment.Finally, for any type of assessment, part of what a professional takes into account is what led to the referral in the first place. For example, an adult seeking therapy for depression, who denies any prior history of any mental health concerns, probably wouldn't be given a full psych evaluation, and a brief depression index (diagnostic questionnaire) won't reveal Anti-social Personality Disorder. Someone referred by the court because they are charged with a serious crime would have a much more in-depth evaluation.

Yes, in many cases this is true. I would often make a guess about IQ based on the brief interview before I would administer a full IQ test. My guess was usually within the standard error of measurement and frequently nailed it. With a little practice it wasn’t too hard. I must have administered several thousand individual IQ tests. Vocabulary is the best estimate of verbal intelligence so by gauging the words that people use you can assess IQ. You might miss some splinter nonverbal strengths or weakness, but the various aspects of intelligence are generally highly intercorrelated. I occasionally would be fooled by folks who were very attractive, glib, or ones who did not look their chronological age, but that was error. Psychiatrists and psychologists frequently estimate intelligence when conducting mental status exams.