Mental Status Exam Template: Descriptors and 2 Examples

A mental status exam template is only as useful as the words you put into it. This guide gives you one to copy, one field per line, plus a quick checklist for routine sessions. It also covers all 11 domains of the mental status exam in plain language, with the descriptors clinicians use and the questions worth asking, and two complete examples: a stable outpatient, and a client with acute anxiety and passive thoughts of death, written with the risk wording a reviewer looks for. You'll also see where the MSE goes in SOAP and DAP notes, the mistakes that make an MSE useless, and what changes over video.

Every client in this article is invented. Any resemblance to a real person is a coincidence.

What is a mental status exam?

The mental status exam (MSE), also called the mental status examination, is a structured description of how a client presents right now: how they look, act and speak, what they feel and think about, what they perceive, how clear their thinking is, and how well they understand their situation. It is the mental health version of the physical exam. Adolf Meyer outlined a standard method in 1918, and the same broad categories are still used across psychiatry, primary care and therapy (StatPearls).

Three things set the MSE apart from the rest of your note:

When to do one:

Comparing one MSE with the last is how you see whether symptoms are improving or worsening (StatPearls). The American Psychiatric Association's guideline on evaluating adults lists a mental status examination, covering mood, anxiety, thought content and process, perception and cognition, along with current thoughts of suicide or harming others, as part of the initial evaluation (APA Practice Guidelines for the Psychiatric Evaluation of Adults).

How to do a mental status exam in a therapy session

You don't need a separate exam. Most of an MSE comes from the session you're already having.

The 11 domains of the mental status exam, with descriptors

Each domain below has a plain definition, what to look for, the words clinicians use, questions where questions are needed, and one weak line rewritten. Some templates fold behavior into appearance, or insight and judgment into one line, and some split motor activity out on its own; the content is the same. For more words in each area, keep our therapy progress notes cheat sheet open beside this page.

1Appearance

What it is: how the client looks: apparent age compared with their stated age, grooming, hygiene, dress and anything clinically notable.

What to look for and the words to use:

Read appearance against the person's life. Money, housing, work, disability and personal style all shape how someone dresses. StatPearls also cautions that when someone who has always been well groomed suddenly declines, mental illness shouldn't be the first explanation you reach for: rule out medical causes too. Describe scars neutrally and only when they're relevant ("healed linear scars on left forearm").

Weak: "Appearance WNL."

Better: "Appears stated age. Casually dressed and clean; hair unwashed and in the same sweatshirt as last week, a change from her usual."

2Behavior (including motor activity)

What it is: how the client acts in the session: their attitude toward you, how they engage, eye contact and movement.

What to look for and the words to use:

Questions: usually none. This domain is observed.

Weak: "Client was resistant."

Better: "Guarded for the first 10 minutes, answering in a few words; engaged fully once we discussed her son. Bounced her right leg throughout."

3Speech

What it is: how the client talks, not what they say.

What to look for and the words to use:

Pressured or just fast? Pressured speech is rapid, hard to interrupt and keeps going after you try to come in. Anxious speech is often fast but stops when you interrupt. Use "pressured" only when it fits, because it points toward mania or intoxication.

Speaking in a second language can change rate and fluency, and an accent is not a finding. New slurring or trouble finding words, by contrast, can signal a medical or neurological problem and is worth raising with the client's doctor.

Weak: "Speech normal."

Better: "Speech soft and slow, with pauses of several seconds before most answers; fluent, no slurring."

4Mood

What it is: the client's own description of how they've been feeling, usually over recent days. You ask, and you record their words in quotation marks.

Questions you can ask:

Words for a summary, if your template wants one next to the quote: euthymic (even, neither low nor elevated), depressed, anxious, irritable, angry, numb, hopeless, elevated. The quote does more work than the label.

If the client can't name a feeling, record that too: "Unable to describe mood; said, 'I don't know, just tired.'"

Weak: "Mood depressed."

Better: "Mood: 'flat, like nothing matters.' Rated 3/10 (5/10 last week)."

5Affect

What it is: the emotion you observe in the client's face, voice and posture. Mood is what the client tells you. Affect is what you see. When the two don't match, say so. The mismatch is often the most useful finding in the MSE.

The words to use:

Affect alone doesn't make a diagnosis (StatPearls). Medication, neurological conditions, culture and autism can all change how much emotion a person shows. Compare with the client's usual.

Weak: "Affect appropriate."

Better: "Affect anxious and restricted; tearful once when discussing her mother, recovered within a minute. Congruent with stated mood."

6Thought process

What it is: how the client's thoughts connect, in the order they come out. This is the form of thinking, not its content. A typical thought process is linear and goal-directed: you can follow the client from your question to their answer.

The words to use, in plain terms:

A quick test for circumstantial versus tangential: did the client answer your question in the end? If yes, it was circumstantial.

Questions: none. It's observed while you talk.

Weak: "Thought process WNL."

Better: "Thought process linear and goal-directed, with circumstantial detail when describing work; returned to each question without prompting."

7Thought content, including risk

What it is: what the client is thinking about. That includes their main concerns and any thoughts of suicide, self-harm or harming others, delusions, obsessions and phobias.

What to look for:

When thoughts of suicide are present, the APA guideline lists what to assess, including active or passive thoughts of suicide or death, plans and intent, the client's intended course of action if symptoms worsen, access to means including firearms, and reasons for living (APA). Most clinicians also ask about preparation, recent timing and past attempts. Use the screening tools and training your setting requires, such as the Columbia Suicide Severity Rating Scale (C-SSRS) and the Stanley-Brown Safety Planning Intervention. Duty-to-protect laws on threats to others differ by state.

How to word it in the MSE:

Questions you can ask:

Weak: "No SI/HI."

Better: "Preoccupied with her divorce hearing next week. Asked directly about thoughts of suicide, self-harm and harming others: reported none. No delusions expressed."

8Perception

What it is: experiences through the senses that other people don't share, or that distort something real.

What to look for and the words to use:

What isn't automatically a symptom: images or sounds while falling asleep or waking (hypnagogic and hypnopompic experiences), seeing or hearing a loved one soon after they died, and experiences that are normal in the client's religion or culture (StatPearls). Ask how the client and their community understand the experience.

Questions you can ask:

Weak: "No AH/VH."

Better: "Denied hallucinations when asked. Described feeling 'like I'm watching myself in a movie' for a few minutes during each panic attack (depersonalization). Not observed responding to internal stimuli."

9Cognition and orientation

What it is: how alert the client is, whether they know who and where they are, the date and what's happening, and how well they attend, remember and reason. In outpatient therapy, you assess most of this through conversation and test formally only when something suggests a problem.

What to look for and the words to use:

If cognition looks impaired, use a validated cognitive screen your setting supports, or refer for medical or neuropsychological evaluation. The MMSE is one such screen, and it is separate from the MSE (more below).

Weak: "Cognition intact."

Better: "Alert; oriented to person, place, date and situation. Lost track of two questions and asked for them to be repeated; recalled last week's breathing exercise and its steps without prompting."

10Insight

What it is: how well the client understands their difficulties, how those difficulties affect them, and whether they need help.

The words to use: good, fair, limited (or partial), poor, absent. Some psychiatry textbooks describe six levels, from complete denial of illness to full emotional insight. In an outpatient note, a word plus your evidence is usually enough, because "fair" on its own tells a reader nothing.

Evidence to look for: whether the client sees a problem at all; whether they recognize symptoms as symptoms; whether they link them to triggers or patterns; whether they see a role for treatment, or place the cause entirely on other people.

Questions you can ask:

Weak: "Insight fair."

Better: "Insight fair: links her panic attacks to the layoff news, but calls the worry 'just realistic' and doesn't see it as something therapy can change."

11Judgment

What it is: the client's ability to make sound decisions about safety, health, money, relationships and daily life.

Judgment is best read from what the client has actually done recently, which StatPearls notes is how it is often assessed: through history and observed actions. The classic hypothetical question about what you'd do with a stamped, addressed envelope found on the street tells you much less than this week's real choices.

The words to use: good, fair, limited, poor, impaired, always with evidence.

Weak: "Judgment poor."

Better: "Judgment fair: called his sister for a ride instead of driving after drinking on Saturday; still checks job listings until 2 a.m., which he agrees is worsening his sleep."

A mental status exam template you can copy

Paste this into your intake or session note, fill in what applies and delete what doesn't. Keep the order: it is the one reviewers expect. The last three lines matter more than they look: what changed, what limited the exam, and who did it.

A quick mental status exam checklist for routine sessions

You don't need the full template every week. For an ongoing client, run this checklist in your head during the session, then write a short MSE: two to five sentences covering every domain, with a concrete detail for anything that changed. Print this section or save it as a PDF from your browser's print window if you want it on your desk.

"Usual for client" only works if the client's usual is written down somewhere, which is what the full MSE at intake is for. If you can't point to that baseline, describe the finding instead.

Mental status exam example 1: a stable outpatient

Invented client: a 46-year-old high school chemistry teacher we'll call Elena, in her 14th session of cognitive behavioral therapy for depression that has mostly lifted. Seen in the office.

The same MSE, written short for a routine progress note:

MSE: Appears stated age, well groomed, cooperative with steady eye contact. Speech normal. Mood "pretty good, tired" (7/10, up from 6/10). Affect euthymic, full range, congruent. Thought process linear; content focused on work and her father's health. Asked about thoughts of suicide and of harming others: none reported. No perceptual disturbances. Alert and oriented in conversation; attention and memory intact. Insight and judgment good (names her own warning signs; kept her evening work limit). No change from last session.

Why this example works:

Mental status exam example 2: acute anxiety with passive thoughts of death

The sessions that most need a careful MSE are the hardest to write. This example shows documentation, not a way to assess risk: follow your training, your setting's risk policy and your state's rules.

Invented client: a 31-year-old paralegal we'll call Marcus, in his fourth session for generalized anxiety. Since the last session he learned his job will be cut in six weeks, has had two panic attacks and is sleeping three to four hours a night. Seen by video.

The MSE records findings. Here is what goes with it in the rest of the same note.

Assessment, risk lines: Passive thoughts of death are new since the last session, alongside acute stress from the job loss, panic attacks and severe sleep loss. He reports no plan, intent, preparation or past attempts, and there are no firearms in the home. Protective factors: close ties to his mother and partner, engagement in treatment, and plans for the future (he is applying for jobs). Risk is higher than his baseline. Outpatient care with a written safety plan and closer contact is appropriate at this time, and risk will be reassessed at each contact.

Plan, risk lines: Wrote a safety plan with the client: his warning signs, steps he can take on his own, people he can contact, and crisis lines, including calling or texting 988. He saved it on his phone and agreed to share it with his partner tonight. Therapist will call him Thursday for a brief check-in, documented as a separate contact note. Next session moved up to Monday. With his signed release, therapist will contact his primary care doctor about sleep before that visit. Repeat the risk questions at the next session.

Why this example works:

How to write the MSE into SOAP and DAP notes

The MSE isn't a separate document for ongoing clients. It's a few lines inside each progress note, and a full section in your intake assessment.

Here is example 2 as a SOAP Objective section. The GAD-7 was sent to the client before the session and scored by the therapist.

O: Session by video; client at home in Ohio (address confirmed), alone in a closed room. GAD-7 total 17 (12 at intake). MSE: appears stated age, unshaven, hair uncombed, dark circles. Cooperative; restless, rubbed his neck and face often. Speech rapid, not pressured. Mood "on edge all the time" (anxiety 8/10). Affect anxious, restricted, briefly tearful, congruent. Thought process linear, circumstantial at times. Thought content: preoccupied with the layoff and money; passive thoughts of death on two nights ("a relief to just not wake up"); asked about plan, intent, preparation and past attempts: none of each; no firearms at home; no thoughts of harming others. Derealization during panic attacks only; no hallucinations. Alert, oriented x4; needed two questions repeated. Insight good; judgment fair (late-night checking of job listings and his bank account). Limits: video, head and shoulders only.

And the start of the same session as DAP Data, where the client's report and the MSE sit together:

D: Client reported learning that his job will be cut in six weeks, two panic attacks since the last session and three to four hours of sleep a night. GAD-7 total 17 (12 at intake). Presented unshaven and restless, rubbing his neck and face; speech rapid but not pressured. Mood "on edge all the time" (anxiety 8/10); affect anxious and restricted, briefly tearful about his mother...

Three rules keep the MSE useful inside a progress note:

For the wording of everything around the MSE, from session details to risk to the plan, see the progress notes cheat sheet.

Telehealth: doing a mental status exam over video or phone

Most of the MSE works well over video. What changes is what you can see, and what you need to set up before the session starts.

Before the session, record the client's location, emergency numbers near that location, a local emergency contact, and a plan for what to do if the connection drops during a crisis. HHS guidance for telebehavioral health lists these steps and notes that 911 only works if you are in the same place as the client (Telehealth.HHS.gov). Psychologists will also find the APA Guidelines for the Practice of Telepsychology, updated in 2024, useful for the wider picture.

What changes in each domain:

Audio only: you lose appearance, eye contact, visible behavior and most of affect. You keep speech, mood, thought process, thought content, perception and much of cognition. Write "Audio-only session; appearance and affect not observed" so no one reads the gaps as normal findings.

Before you choose a video platform, check that the vendor will sign a Business Associate Agreement with you. Our guide to whether Google Meet is HIPAA compliant walks through what to check for any platform, and your informed consent is the place to explain your telehealth emergency plan.

Adjusting the MSE for different clients

The MSE vs the MMSE and other cognitive screens

The names are close, but these are different things.

Other brief cognitive screens exist, such as the Mini-Cog, the Montreal Cognitive Assessment (MoCA) and the revised Addenbrooke's Cognitive Examination. A family medicine review describes the Mini-Cog and the revised Addenbrooke's as preferred alternatives to the MMSE for dementia screening, and the MoCA as a preferred alternative for detecting mild cognitive impairment (American Family Physician). Each tool has its own terms of use and, for some, training requirements, so check them before you use one. None of them diagnoses anything on its own, and none replaces the MSE. If a screen is positive, it is a reason to refer, not a conclusion.

Common mental status exam mistakes

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions and session notes in one place. Here is where an MSE fits.

practice.tranqbay.health shows a session's page, from the video call to the note written after it, if you want to see where your MSE would sit before you set anything up.

Frequently asked questions about the mental status exam

Before your next session

Copy the template into your intake note, keep the quick checklist beside you for routine sessions, and write one concrete detail behind every word you choose. An MSE that a colleague could picture is one that will still mean something six months from now.

If you'd also like your booking, video sessions and session notes in one place, see how TranqBay works for private practice: you can look at a practice website template and the booking page your clients would use. If you're deciding whether to join, this page explains how joining TranqBay works.

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