Mental Status Evaluation



Informed consent obtained for purposes of this evaluation was obtained about:

ڤ  The participant in this evaluation 

ڤ  Confidentiality

ڤ  Competency

ڤ  Other:________________________________________________________________________

Evaluation Methods

The information provided is based upon observations of the officer during the:

ڤ  Intake interview

ڤ  Testing

ڤ  Group Session

ڤ  Other:_____________________________________________________________________________

Mental Status Description (Please list or circle most factual items pertaining to officer)

Height                 ________

Weight                 ________

Clothing              Neat and clean     Careless     Inappropriate     Meticulous     Disheveled     Dirty      

                            Inappropriate       Appropriate for age         

Grooming           Normal       Well-groomed       Neglected      Bizarre                 

Motor activity    Not remarkable     Slowed    Repetitive     Restless     Agitated     Tremor or shakes

Posture              Normal       Tense      Rigid      Stooped      Slumped      Bizarre  


Attention           Normal     Unaware     Inattentive     Distracted     Confused      Persistent    Vigilant


      Speech flow        Normal     Mute     Loud      Blocked      Paucity      Pressured      Flight of ideas



                          Normal      Scattered      Variable      Preoccupied    Anxiety    Focuses on irrelevancies


                        X5       Time                  Person             Place           Situation         Object

Memory          Normal        Immediate memory impaired       Recent memory impaired 

                       Remote memory impaired 


       Eye contact    Normal       Fleeting        Avoided         None          Staring

       Facial Expression

                            Responsive      Constricted      Tense      Anxious     Sad     Depressed     Angry

       Attitude toward examiner

                           Cooperative       Dependent       Dramatic      Passive      Uninterested      Silly

                           Resistant        Critical      Hostile     Sarcastic     Irritable     Threatening/Intimidating

                           Suspicious        Guarded        Defensive        Manipulative       Argumentative

       Affect          Appropriate   Labile   Restricted   Blunted   Flat   Other:____________________________

       Mood           Pessimistic   Euthymic   Depressed   Hypomanic  Euphoric   Other:___________________

      Speech Flow

                      Normal       Mute      Loud       Blocked         Paucity       Pressured      Flight of ideas  Rapid

     Thought Content

                    Appropriate to mood and circumstances    Personalizations     Persecutions      Suspicous

                    Delusions      Ideas of reference     Ideas of influence       Illusions       Obsessed


                   Phobias    somatic    Suicide   Homicidal    Guilt   Religion   Sex




                     Auditory    Visual   Other:______________________________________________________


                     Logical            Goal-directed            Circumstantial             Loose            Persecutions  

Executive Functions

Fund of knowledge

                   Average    Impoverished by: ____________________________________________________


                  Average            Below average            Above average            Needs investigation


                 Normal        Concrete        Functional        Popular       Abstract        Overly abstract


                 Normal          Common-sensical           Fair          Poor          Dangerous

Reality Testing

              Realistic           Adequate           Distorted          Variable        Unaware


              Uses connection        Gaps          Flashes of          Unaware         Nil         Denial

Decision making

             Normal         Only simple         Impulsive       Vacillates       Confused      Paralyzed


             Money         Housing        Family conflict       Work     Grief/losses       Illness      Transitions

             Administrative paperwork          shift changes       lack of say       Danger on the job

            Recent use of firearm       Death of co-worker           Other:_______________________

Coping ability

           Normal     Resilient     Exhausted    Overwhelmed    Deficient supports    Deficient skills    Growing


Skill deficits

          Intellect/education       Communication      Interpersonal        Decision making     Self-control

          Responsibility       Self-care        Activities of daily living      Impulsive           Prone to anger


         Usual        Family        Friends        Church        Service system       Peer Counseling       Psychologist 


Social Functioning:

Social Maturity

        Responsible        Irresponsible       Self-centered         Impulsive         Isolates

Social judgment

        Normal       “Street-smart”      Naïve       Heedless      Victimized      Impropriety

Other aspects of mental status:



This is a strictly confidential patient record.  Re-disclosure or transfer is expressly prohibited by law.  This report reflects the client’s condition at the time of consultation or evaluation.  It does not necessarily reflect the patient’s diagnosis or condition at any subsequent time (Zuckerman, 1997).



l.        Obtain the officer’s commitment to engage actively in treatment/therapy.

m.    Perform extensive Bio/Psych/Social (Refer to following example).





The Client is a 50-year-old, heterosexual, male of Caucasian & African-American descent that is having suicidal ideation.  The client was appropriately dressed in aloha shirt and pants.  His manner and attitude towards the interviewer was cooperative.  He did get liable on several occasions while talking and especially when he talked about his family.  He reports that he has had violent and angry episodes and has taken anger management courses.  The client also reports that he drinks heavily and has been depressed.  He also has unpleasant memories of being killed in the line of duty.  The client reports that his former superior for harassed him while he was assigned to the Criminal Investigation Division.  He also indicated during the interview that it was the “police departments fault” for many of his current problems.  The client reports that he has recently been placed on administrative leave due to his alcohol dependence.  He states that the administration provides no support for police officers.  The client also expresses anger towards his former superior.  The client was assessed for lethality but denies any homicidal ideation.


History - Presenting Problem:


The client was born and raised in California.  His mother was a housewife and his father died in 1970.  He moved out of his mother’s home at 16 years of age and has been on his own since that time.  He attended High School and held a variety of jobs, and then joined the military.  The client reports that he has had two years of college.  He joined the police department in 1983.  He has had a series of unstable relationships until he met his common law wife of 15 years.   The client reports that his wife is verbally abusive but that he does not want to lose his family.  He has been drinking since he was 18 years old.  His drinking escalated to daily use.  He has reported that he suffers from physical problems,  mental difficulties and family problems as a result of his drinking.  Client also has physical problems which he stated are a result of serving in the police department.  These include headaches, and gastrointestinal problems.  The client also displayed several scars on his stomach and leg during the interview.  The client reports that he has been attacked while on duty and during arrests.  He also states that he witnessed the death of another officer during an arrest during his second year in the police department.  The client also stated that he is trying to “wipe memories out of his mind and that he fears that he will lose his memory.  He stated that he enjoys spending time with his children and that he has compassion for fellow-human beings.  He does not report having had any legal problems.   He has a prescription for and is using valium.  The client also smokes 1 pack of cigarettes

daily.  His affect was tearful about his relationships with his family.  His emotions appeared sincere at the time of the interview.


DSM IV Criteria:



Clt. meets 3 out of 7 criteria out of DSM IV for 303.9 for Alcohol Dependance with emphasis on:



(6)            The substance is often taken in larger amounts or over a longer period

             than was intended.


(6)            Important social, occupational, or recreational activities are given up or reduced because of substance use.


(7)            The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.



 AXIS I CD:   303.9 Polysubstance Dependance, R/O

                     PTSD,  R/O Generalized Anxiety Disorder and

                     Adjustment Disorder with Mixed Disturbance of Emotions and


AXIS I :        Client `Reports Depression.

AXIS II:        R/O Paranoid Personality

                    Disorder, R/O Borderline Personality Disorder. 

AXIS III:       Clt. Reports gastrointestinal problems and headaches.    

AXIS IV:       Economic, occupational, family discord, and lack of social 


AXIS V:       GAF = 60


History - Social:


Client is of Caucasian and African-American descent.  Clt. was born in California and was raised with father and mother.  Clt’s. father passed away in 1970.  Client stated that he moved out of parent’s home at 16 years of age.  Client completed high school and had 3 years of college.  He joined the police department in 1990 and was placed on administrative leave for his excess drinking.  He reports that he is self-supporting.  He has experienced suicidal ideation.  He reports that he recently had heated altercations with his spouse and left home.  He stated that he has fears of losing his family.  The client also reported that he experiences troubling memories of his superior acting in an abusive manner towards him while in the Criminal Investigative Division.


ASAM Dimensions:


Clt. meets ASAM PPC2 criteria for placement at Residential Level of TX AEB:


Dim I  -     Clt. Reports no withdrawal symptoms at this time. = (L) 

Dim I -      Clt. Reports medical problems at this time.  Client has gastrointestinal problems 

                  Syndrome and headaches. = (M)

Dim III -   Clt. Has biomedical complications that requires medical monitoring, but not

                  intensive care.  Clt. reports that he is experiencing depression, is

                  confused and has had suicide ideation.= (M)   

Dim IV -   Clt. Has poor relapse prevention and coping skills. Clt. is referred by EAP.

                  Client requires intensive motivating

                  strategies, activities and processes available only in a 24-hour structured

                  environment. Client does not accept or relate serious consequences and effects

                  of addiction. = (M-H)

Dim V -     Clt. is unable to control alcohol use.  The modiality of treatment can be

                  administered or followed only in a 24-hr. controlled, supervised environment.   

                   = (H) 

Dim VI -    Chaotic family or interpersonal conflicts undermine client’s efforts to change.

                   Clt. is homeless and little clean and sober support.  Client also reports

                   economic problems, problems with his superiors and workplace, and problems with family as a result of his

                   alcohol abuse.   =  (H)




Goals for TX include education of relapse prevention skills and the disease concept, and the enhancement of c/s support network.  Clt. would also benefit from long term therapy for possible PTSD.  The goal of treatment is to aid in Clt.’s self-assessment and comprehension of his substance dependence.   Upon stabilization of the client, anger management and stress management education is also recommended.





___________________________________            Date_____________     

  Pamela J. Fitzgerald, MSCP, MSCJA


·          This example does not make reference to any real or fictitional person/s and is meant as a guideline only  for said purposes of obtaining history for diagnosis and treatment planning.


·          The “client” from the bio/Psych/Social Assessment will be used to provide further examples throughout this crisis plan.





n.      Determine appropriate intervention and treatment plan bases upon the assessment.

o.      Outline treatment plan for the officer and obtain signature for treatment.

p.      Determine if additional psychological testing is needed and administer appropriate tests (Refer to attached “Stress Survey”, Appendix A).

q.      Is the officer injured?  Are there any other officers injured?  Have firearms been discharged?  Was or is this a hostage situation?  It will be important to identify the exact nature of the crisis situation.  If there have been injuries then the emergency services will be called in immediately.  Identify how many people have been involved in the injury.  Is someone in the area that knows CPR, should it be required?  Does CPR need to be administered?

r.       Emergency equipment such as defilberators, first aid kits, protective masks for administering CPR, and fire extinguishers are to be on hand at all times.  The crisis response personnel shall be made aware of where all equipment is.  All employees should also have training in use of the equipment, as well as knowledge of all exits.

s.       Other training in natural disasters, bomb threats, fire, helicopter crashes, police vehicle accidents, and other major emergencies should be provided to the individuals responsible for crisis intervention. 



Part II: Insure Safety,

 Identify the Solution to the Crisis and Administering Aid and Treatment to the Officer/s.

     Upon completion of the assessment of the crisis situation, it will be imperative to find the appropriate solution.  The officer or client should have been assessed for lethality.  A thorough checklist or guideline for assessment of lethality should be utilized.  An example of this would be P.L.A.I.D. & P.A.L.S.  All crisis personnel should be thoroughly familiar with these assessment tools.  The crisis personnel or therapist must inform the officer of his or her confidentiality rights along with informed consent.  The appropriate forms should be signed.   The following is the lethality checklist:

What to look for when an officer is suicidal


Plan    Does the individual have a specific plan?

Lethality  Is the plan realistic?  Is the plan dangerous?

Availability?  Do they have the means to carry the plan out?

Illness    Does the individual have a mental or physical illness?

Depression  Does the individual have a history of depression?


Previous Attempts   How many?  How recent are the attempts?

Alone  Is the individual alone?  Does the individual have a support system?

Loss  Have they suffered a recent loss?

Substance Abuse  Is the individual using alcohol or drugs?  How long has the individual been abusing the substance?  How much has the individual used?

The more questions that the individual answered yes to, the more at risk the person is.  If you fear that someone is suicidal, then an MH1 can be executed.

Availability can be considered a “yes”, since the majority of police officers own and have access to firearms.  Appropriate steps must be taken if an officer if in imminent danger of being a threat to him/herself or to other officers or individuals.  Any threats made by a police officer must be taken seriously.

What safety measures are in place?  A solution to the crisis cannot be applied effectively unless the officer/s is safe.  Additionally, in order for the solution or treatment plan to have the desired goal or objective, there must be a continuum of safety provided to the officer.

Some questions to consider for insurance of safety:

Are firearms involved in the crisis? 

How can the firearm be removed without causing further harm?

Does the individual have access to prescription medicine or drugs?

Has the individual been addicted to drugs or alcohol?

How long has the individual been using drugs or alcohol?

Has the client been stabilized? 

What measures were taken to stabilize the client?

Does the officer need to be hospitalized or see a physician?

Does the officer have any presenting problems either psychologically or physically?  Is the officer diagnosed with any DSM-IV disorders?  Is there any pathology?

Are other officers or individuals in danger and how can they be stabilized?

What services and outside agencies provide support? What are the appropriate agencies to make referrals to?

Is there support for the family members of the officers?

Is a change of assignment necessary to effect safety for the officer/officers?

What problems could arise in the future as a result of the initial crisis?

Determining the objective and putting the solution in place.

     The crisis personnel shall utilize the appropriate solution to meet the needs of the officer/s undergoing the crisis.  The first step, establishing the nature of the problem has been completed.  The next step is to ascertain the objective, the goal, the method employed, measurement of progress.  Once the treatment plan or solution has been implemented consistency and follow-up is required in order to maintain a continuum of stability.  The situation itself can cause the individual/s involved to decompensate.  The crisis personnel should review the treatment plan.  The solution should have measurable goals in order to determine that it is indeed the appropriate solution.  Constant monitoring of the individual/s after the crisis has passed will also enable the crisis personnel to change the plan to address other needs that the officer/s may develop.  A guideline of a treatment plan is provided on the following page.  This can be utilized as a model for this phase of the crisis intervention.