Mental Status Exam Narrative. Stan is a thirty-two . OF COUNSELING: Example: Group Counseling _____ Xs weekly. Couples Counseling _____ Xs weekly. SAMPLE INITIAL EVALUATION TEMPLATE . Mental Status (circle appropriate items) . Past Psychiatric History (Mental Health and Chemical Dependency): . Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress . Sample Type / Medical Specialty: Psychiatry / Psychology WORK GROUP ON PSYCHIATRIC EVALUATION. Michael J. ... For example, patients who have presented with intoxication or who have received medications. A mental health assessment gives your doctor an overall picture of how well you feel . For example, it may be used to find out if a child has a learning disability, .