02 Assessment and Care Planning

Purpose and approach

A Mental health assessment is a structured, collaborative process for understanding a person’s concerns, strengths, safety, health, and support needs. It informs care but does not by itself establish a diagnosis. A thorough assessment brings together the person’s account, observed presentation, relevant history, and—when appropriate and with respect for privacy and consent—information from other sources.

New or unexpected changes in mental state may have medical, medication-related, or substance-related causes, so they warrant appropriate medical evaluation.

Gathering a person’s history

Begin by explaining your role, the purpose of the conversation, confidentiality and its limits, and how information will be used. Ask open-ended, nonjudgmental questions, then clarify relevant details. For example, ask, “What has been hardest for you lately?” and follow with questions about when it began and how it affects sleep, work, relationships, or daily activities.

Attend to the person’s language, culture, communication needs, and preferences. Explore relevant concerns in the following areas:

• Present concerns: onset, duration, frequency, severity, triggers, changes over time, and effects on daily functioning.

• Mental and physical health history: prior symptoms, diagnoses, treatment, hospitalizations, medical conditions, sleep, pain, and recent health changes.

• Medication and substance use: prescribed and nonprescribed medicines, recent changes, alcohol and other substances, and possible effects or withdrawal.

• Personal and social context: relationships, housing, work or school, culture, identity, trauma or loss, financial pressures, and access to care.

• Strengths and supports: coping strategies, valued roles, goals, supportive people, and what has helped before.

Consider both the person’s subjective experience and observable information. Document relevant findings clearly, distinguish the person’s report from your observations, and avoid assumptions.

Describing current mental functioning

The Mental status examination (MSE) describes a person’s current presentation and mental functioning. It is a snapshot to interpret in context, not a diagnosis. Describe specific findings neutrally rather than relying on labels; for example, “speech was quiet, with long pauses” is more informative than “withdrawn.” When information is available, compare findings with the person’s usual functioning.

Common domains include:

• Appearance and behavior: dress, grooming, posture, eye contact, activity level, cooperation, and ability to engage.

• Speech: rate, volume, rhythm, fluency, and whether responses are spontaneous or delayed.

• Mood and Affect: Mood is the person’s reported emotional state. Affect is the emotion conveyed through expression, tone, and behavior; note its range and whether it appears consistent with the conversation.

• Thought process: how ideas are organized and connected, such as whether they are coherent, slowed, rapidly shifting, or difficult to follow.

• Thought content: preoccupations, fears, unusual beliefs, hopelessness, thoughts of self-harm or suicide, and thoughts of harming others. Ask respectfully and directly when indicated.

• Perception: experiences such as hearing or seeing things others do not; clarify what the person experiences and how distressing or commanding it is.

• Cognition: alertness, attention, orientation, memory, and language, as appropriate. Consider communication, education, culture, and sensory needs when interpreting results.

• Insight and judgment: the person’s understanding of their experiences and how they assess situations or make decisions. Avoid treating a single response as definitive.

Screening for risk and responding to danger

Ask directly and calmly about safety when concerns, symptoms, history, or a screening result indicate a need. Risk screening can help identify who needs further evaluation, but a positive screen is not a complete risk assessment. Follow the setting’s clinical pathway and involve a qualified clinician as required.

For suicide concerns, assess current thoughts, their timing and frequency, any plan and access to means, past attempts or self-injury, acute stressors, supports, and reasons for living. Also consider risk of harm to others, abuse or exploitation, inability to meet basic needs, and vulnerability related to confusion, intoxication, or severe distress. Ask about immediate danger and the person’s own view of what would help them stay safe. Protective factors and denial of intent are important information, but neither by itself rules out danger.

If there is imminent danger, current suicidal intent, or the person cannot be kept safe, do not leave them alone. Promptly involve the responsible clinician and follow emergency procedures. Arrange urgent evaluation and reduce access to dangerous means when feasible and safe.

For non-imminent concerns, collaborate on a written Safety plan, identify supportive contacts and professional help, and arrange timely follow-up. In the United States, call or text 988 for the Suicide & Crisis Lifeline; use emergency services for an immediate life-threatening emergency.

Building a collaborative care plan

A Person-centered plan is made with the person, not simply for them. It reflects their priorities, values, strengths, preferences, and desired outcomes while addressing clinical and social needs. Invite the person to choose who participates, when appropriate, and provide information in a form they can understand. Shared planning supports informed decisions and coordination across providers and settings.

A useful plan brings together:

1. Priority concern and desired outcome: use the person’s own words where possible.

2. Specific goal: make it concrete and achievable, with an agreed timeframe.

3. Actions and supports: clarify what the person, care team, and chosen supports will do, including preferences and practical barriers.

4. Safety steps: when relevant, identify warning signs, coping strategies, supportive contacts, professional or crisis resources, and steps to make the environment safer.

5. Responsibilities and follow-up: specify who will take each action, when progress will be reviewed, and how the plan can be revised.

For example, if anxiety is disrupting sleep and work, the person and care team might agree on practicing one chosen relaxation strategy before bed on four nights each week, identifying a clinician to discuss persistent symptoms, and scheduling a check-in in two weeks. Adjust the plan if the strategy does not suit the person or circumstances change.

Reviewing and coordinating care

Reassess when symptoms, functioning, risks, preferences, or circumstances change. Document the person’s participation, agreed actions, referrals, and follow-up so the plan remains useful and coordinated.

A sound process combines the person’s story and relevant health and social history with observations and a structured mental status examination. Appropriate direct questions about risk guide next steps; urgent danger requires immediate action and follow-through. Collaborative care planning turns the person’s priorities and strengths into clear goals, practical supports, safety steps, and scheduled review.