5150 Evaluation Questions Guide

Behavior and Compliance with Treatment

• What is the recent change in behavior to warrant interviewing the client?
• How long has this behavior been taking place?
• Is the client taking medication as prescribed?
• Is the client refusing any treatment or care?
• Is the client eating full meals?
• Is the client physically aggressive? If so, describe.
• Is the client currently conserved? If so, note the conservator’s full name and contact information.
• What is the client’s mental health history?

When interviewing the client for a 72-hour hold petition, these questions below are to help a clinician decide if the client meets criteria for admission – danger to self, danger to others, or gravely disabled.

Orientation Questions

• What is your full name and birthdate?
• Why are you at the hospital? (If the client can’t tell you, then state why you’re interviewing.)
• What is today’s date?
• What town are you in right now?
• Who is the current President of the United States of America?
• Are you experiencing hallucinations? If so, describe.

Mood Questions

• Are you feeling depressed? Rate 0 out of 10, where “10” is the worst imaginable.
• Are you feeling anxious? Rate 0 out of 10, where “10” is the worst imaginable.
• Do you feel like you want to hurt yourself? If so, describe.
  ○ What’s your plan to hurt yourself?
• How are you getting along with other people where you live?
• Do you feel like you want to harm someone else? If so, describe.
  ○ What’s your plan to harm someone else?

Gravely Disabled Questions

• When is the last time you ate a full meal?
• When is the last time you had a shower or bath?
• When is the last time your clothes have been washed?
• How would you provide clothing, food, and shelter for yourself outside of the healthcare setting?