The template
Mental Status Exam Client: [identifier] Date: [date] Setting: [in person / telehealth] Telehealth (optional): [client's location this session; video or audio only] Appearance: [grooming, dress, hygiene, apparent age, notable features] Behavior: [eye contact, cooperation, psychomotor activity (calm, restless, slowed), any unusual movements] Speech: [rate, volume, rhythm, amount, articulation] Mood (client's own words): "[quote]" Affect: [range (full, constricted, flat), intensity, congruence with mood, appropriateness to content, stability] Thought process: [linear and goal-directed / circumstantial / tangential / flight of ideas / loosening of associations / thought blocking] Thought content: [main themes and preoccupations; obsessions; delusions if any; suicidal ideation (passive or active, plan, intent, means, history); homicidal ideation (if present: toward whom, plan, intent, means)] Perception: [hallucinations (type), illusions, depersonalization or derealization; or none reported or observed] Cognition: [level of consciousness; orientation to person, place, time and situation; attention and concentration; memory] Insight: [good / fair / limited / poor, with a brief reason] Judgment: [good / fair / limited / poor, with a brief reason] Risk summary and actions taken: [ ]
What goes in each domain
Appearance and behavior. Describe what you see without judging it: "wearing the same clothes as last session, hair unbrushed" says more than "poor hygiene". Note eye contact, cooperation and whether the client seems restless or slowed.
Speech. Rate, volume and amount. Pressured speech, long pauses before answers and very sparse replies are all worth recording.
Mood and affect. Mood is what the client reports, so quote them: "pretty flat". Affect is what you observe: its range, intensity, whether it matches the reported mood and whether it fits what they are talking about.
Thought process. How the client's thinking flows. Can they answer a question and stay on track (linear, goal-directed), or do they get there by a long route (circumstantial), drift away and not return (tangential), or jump rapidly between ideas?
Thought content. What the client is thinking about. Main worries and preoccupations, any obsessions or delusional beliefs, and always suicidal and homicidal ideation. For suicidal ideation, record whether it is passive or active, and what you learned about plan, intent, access to means and past attempts. If homicidal ideation is present, record toward whom, plus plan, intent and means, then follow your setting's protocol and check your state's duty-to-warn or duty-to-protect law.
Perception. Hallucinations of any kind, and experiences such as depersonalization or derealization. If none were reported or observed, say so.
Cognition. Alertness, orientation, attention and memory. In most outpatient sessions this is observed informally: the client followed the conversation, recalled last week's homework and knew the date.
Insight and judgment. Insight is the client's understanding of their own difficulties. Judgment is their capacity to make sound decisions. Give a rating and one line of reason.
The MSE is one input to your formulation. For how it fits a fuller clinical picture, see the case conceptualization template and example.
A filled example
All examples on this page are fictional composites. They do not describe real clients.
An adult client in their 40s, seen by telehealth for low mood, session 3.
Appearance: Appears stated age. Casually dressed, hair unbrushed. Seated in a dim room; camera on throughout. Behavior: Gaze mostly downcast, away from the screen. Cooperative. Psychomotor slowing noted: slow to begin answers, few gestures. Speech: Slow rate, low volume, decreased amount. Normal articulation. Mood: "Pretty flat. Like nothing matters much." Affect: Constricted range, low intensity, congruent with stated mood. Briefly brighter when discussing their dog. Thought process: Linear and goal-directed, with long pauses. Thought content: Preoccupied with being "a burden" to their partner. Reports passive thoughts that "it would be easier not to wake up" on several days this week. Denies a plan or intent. Denies access to firearms or stockpiled medication. No history of attempts reported. Denies homicidal ideation. No delusional content elicited. Perception: Denies hallucinations. None observed. Cognition: Alert. Oriented to person, place, time and situation. Attention adequate for the session. Recalled last session's activity plan. Insight: Fair. Recognizes low mood as a problem; doubts treatment will help. Judgment: Fair. Agreed to the safety plan and to tell their partner how they are doing. Risk summary and actions taken: Passive suicidal ideation without plan or intent. Risk factors: low mood, feeling like a burden, doubts treatment will help. Protective factors: partner, dog, engagement in treatment. Judged low acute risk: passive ideation without plan or intent, denies access to firearms or stockpiled medication, no past attempts reported, protective factors present; monitor closely given the risk factors. Safety plan reviewed and updated in session, including crisis line 988. Next session moved up to 4 days from today.
Telehealth limits what you can observe, such as gait, odor, fine motor detail and eye contact (a client looking at the screen is not looking at the camera). It is fine to note what you could not assess.
Common mistakes
- Mixing up mood and affect. Mood is the client's report. Affect is your observation. Record both.
- "Within normal limits" for every domain. It hides what you actually saw. Write one specific observation per domain, even when nothing is unusual.
- Skipping suicidal and homicidal ideation. Ask and record the answer every time an MSE is done, including when the answer is no.
- Interpretation in place of observation. "Manipulative" or "attention-seeking" are judgments. Describe the behavior instead.
- Copying last session's MSE forward. Presentation changes. Record what you saw today, even when little has changed.
- Confusing the MSE with the MMSE. The Mini-Mental State Examination is a separate, scored cognitive screening test. The MSE described here is a structured clinical observation.
FAQ
What is the difference between mood and affect?
Mood is the client's own description of how they feel, so it is best recorded as a quote. Affect is what you observe: the range, intensity and appropriateness of their emotional expression. A client can report a "fine" mood with a tearful, constricted affect, and that mismatch is worth recording.
How often should a therapist complete a mental status exam?
Many settings expect a full MSE at intake and when a client's presentation changes, with brief observations in each progress note. Your agency, payer or licensing board may set its own expectation.
Can you do a mental status exam over telehealth?
Yes, with limits. Speech, affect, thought process and content, and orientation come through well on video. Gait, odor and some motor signs are harder to assess. Note what you could not observe.
What does "oriented times four" mean?
The client knows who they are, where they are, the date or time, and the situation they are in. Some settings record three (person, place, time) and some four. Write out what you checked rather than relying on the shorthand.
This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.