Mental Health Evaluation

[YOUR COMPANY NAME]

Patient Name
Date of Birth
Gender
Evaluation Date
Evaluator

Introduction

This Mental Health Evaluation aims to assess the severity and impact of symptoms on daily functioning. It is essential for understanding an individual's mental health status and guiding appropriate interventions.

Background

Mental health disorders can significantly affect various aspects of daily functioning. Assessing the severity and impact of symptoms is crucial for accurate diagnosis and effective treatment planning.

Guidelines for Severity and Impact Rating

Severity (0-10):

0: Absence of symptoms.
1-3: Mild symptoms with minimal interference.
4-6: Moderate symptoms affecting daily activities.
7-9: Severe symptoms significantly impacting functioning.
10: Extreme symptoms rendering daily functioning impossible.

Impact on Daily Functioning (0-10):

0: No impact on daily functioning.
1-3: Mild impact, occasional disruptions.
4-6: Moderate impact, noticeable difficulties.
7-9: Severe impact, significant impairment.
10: Extreme impact, inability to function.

Evaluation Form

Criteria	Severity (0-10)	Impact on Daily Functioning (0-10)
1. Depressed mood
2. Anxiety
3. Sleep disturbances
4. Impaired concentration and decision-making
5. Social withdrawal
6. Irritability or anger
7. Suicidal thoughts or behaviors
8. Substance use or abuse
9. Hallucinations or delusions
10. Disorganized thinking
11. Appetite changes
12. Fatigue or loss of energy
13. Hopelessness or worthlessness
14. Relationship difficulties
15. Occupational problems

Comments/Feedback

Comments