How to write a mental status exam

Mock Mental Status Exam

Initial Interview
Student

School

Initial Interview

Identifying Information

· Date of interview: March 31, 2018

· Name: Antonio Goodman

· Address: 911 Jefferson Square South Hill, VA 23235

· Phone: 703-174-5742

· DOB: 12/21/1987

· Age: 30

· Marital Status: Married

· Occupation: Senior Probation Officer at WHO, Inc.

· Work Phone: 703-574-4174

· Emergency Contact: Shannon Goodman (wife) 804-901-5921

Reason for Referral

Mr. Goodman was referred by Liberty University for an evaluation. This evaluation is a requirement of the summer’s mission committee in order to screen for appropriateness for participation in an upcoming trip. Mr. Goodman does not foresee any issues that would limit his ability to successfully complete the summer mission.

Current Situation and Functioning

Mr. Goodman is a 30-year-old, married male who is currently residing with his wife and two daughters, Akira (age 6) and Erin (age 3). He was accompanied to the evaluation by her wife, Mrs. Shannon Goodman. Mr. Goodman states that he was comfortable answering all questions in front of his wife. However, Mrs. Goodman excused herself in order to use the time to answer emails. Mr. Goodman escorted his wife to the door and sat back down.

Mr. Goodman presented as well-groomed and wearing seasonally appropriate attire. He is of above average height. He spoke in a clear and coherent voice with an appropriate tone and rate. His intellectual functioning is estimated to be within a normal limit. His vocabulary was quite extensive, and he demonstrated a large amount of knowledge related to religion and criminal psychology. He discussed current political events along with his suggestions for bettering them. He was cooperative and stated that he appropriated the differing views of others.

He describes himself as family-oriented; often drawing strength from his support system. Mr. Goodman states that his greatest strength is his compassion for others. His greatest weakness is wanting to always please everyone. He was pleasant and congenial throughout the evaluation and smiled often. He sat in a relaxed posture as he responded confidently to the various questions. Mr. Goodman utilized humor during difficult topics relating to his father’s death.

His favorite television show is Power, a series on Starz. His leisure activities include going to the movies, volunteering at church, and gardening. Mr. Goodman describes that he manages stress by compartmentalizing the various tasks at hand and developing a plan. His thought process is goal-driven and associative. Mr. Goodman’s eye contact is attentive and appropriate during evaluation.

Family History

Mr. Antonio Goodman is the oldest child of Jamie and Alphonso Goodman. His

parents were married for 34 years before his father passed away in 2012. They met in 1984 at George Mason University. His mother majored in Nursing and his father in Business Management. They both graduated in 1985 with Honors and moved to Alexandria, Virginia to begin their family. Mr. and Mrs. Goodman had three children in all; however, the oldest of the two girls passed away as a child due to pneumonia in 1986. He was born shortly after and his younger sister, Hope, followed in 1989. Mr. Goodman describes his parent’s marriage as strong and their parenting styles as supportive yet demanding. His mother is currently residing with his sister and one-month-old niece in Temple Hills, Maryland.

Educational History

Mr. Antonio Goodman described himself as “busy, mischievous” child. He stated that he occasionally got into trouble in school, but, was often saved due to his athletic football abilities. Mr. Goodman maintained a C average throughout his academic career. He graduated from T.C. Williams High School in Alexandria, Virginia. Then, was accepted to Norfolk State University in Norfolk, VA on a full football-sponsored scholarship.

Mr. Goodman communicates having a few serious girlfriends before meeting his wife in 2009. They at a Greek social event as Mr. Goodman was a member of Phi Beta Sigma Fraternity, Inc. and Mrs. Goodman was a member of Zeta Phi Beta Sorority, Inc. In 2011, they graduated. He obtained a degree in Criminal Justice and Mrs. Goodman received a degree in Recreational Therapy. Mr. Goodman describes college as one of the best times of his life. He expresses that he received recognition from various honor society and impressed his parents by graduating with Honors just as they did.

Employment History

Mr. Goodman described that after his father passed, he “temporarily lost” his way. He bounced around from job to job; with most of them being inapplicable to his degree. He communicates never having a solid job during this time due to his parents enforcing the priority of academics. However, after his father passed away, his mother could no longer able to assist her financially as much. As a result, he applied for a paid internship with a law firm in Richmond, Virginia and moved along with his then-girlfriend, Shannon Erikson. Mr. Goodman expresses that he has been working for the same company since he was an intern. Now, he is employed as Senior Probation Officer for more than 15 years.

Relationship History

In 2012, Shannon and Antonio conceived their first daughter, Akira. After four years of dating, they were married in a small courtroom in 2013. In 2015, their second daughter, Erin, was born. Mr. Goodman states that he has been coaching his girls’ soccer team for the past two years. He communicates that he has only two close friends whom his known since childhood. His support system is compromised of his mother, his sister, his wife, his daughters, and his two childhood friends.

Development History

Developmentally, he describes that his mother’s pregnancy was within normal range; he was born 9 pounds 5 ounces. In 2013, Mr. Goodman expresses that he found the church and discovered a new meaning to life. In early 2014, he devoted his life to Christ and been taking classes at Liberty University to major in Christian Counseling. Mr. Goodman has been currently volunteering by mentoring at-risk youth in Downtown Richmond.

Relevant Medical History

Mr. Goodman appeared to be in favorable health as evident by his lack of medical problems. He expressed that following the death of his father, he began eating better. Mr. Goodman stated that his father passed away in 2012, after battling with prostate cancer for many years. At that point in time, Mr. Goodman transitioned to a plant-based vegan lifestyle. He expressed that at his heaviest weight, he weighed over 360 pounds. Currently, with the help of diet and exercise, Mr. Goodman has lost 120 pounds. He denies any medical issues, but, stated that he does have a family history of high blood pressure, diabetes, and cancer.

Mr. Goodman is monitored regularly by his primary care physician, Dr. Williams at Commonwealth Family Practice. He is not prescribed any medications; however, he disclosed that he does take daily vitamins, allergy medications, and will occasionally administer Aleve for pain.

Counseling Experiences

Mr. Goodman expresses that he and his wife visit a marriage counselor periodically to work on their communication issues. He describes is six-year as stable and rewarding; however, their marriage hasn’t always been. He stated that losing the patriarch of the family impacted him more than he thought it would. Mr. Goodman describes being prescribed Ativan 0.5mg for a short period of time by a psychiatrist to deal with his vivid nightmares. However, after working with a psychologist and engaging in talk and art therapy, he was able to learn new positive coping skills for his grief. Mr. Goodman describes that he continues to check-in with his treating psychologist twice a year, but, reports any current issues. Mr. Goodman denies any history of suicidal or homicidal ideations. He also denies any associations related to delusions and hallucinations.

References Drummond, R. J., Sheperis, C. J., & Jones, K. D. (2016) Assessment Procedures for Counselors and Helping Professionals, CourseSmart eTextbook (8th ed.). Upper Saddle River, NJ: Pearson.