ANNUAL UPDATE



Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX TransgenderSECTION I: Reason for Update – This section may be completed by an unlicensed provider FORMCHECKBOX Annual Update FORMCHECKBOX Re-Admission FORMCHECKBOX Interim Update of New InformationDate of Most Recent Comprehensive Assessment: FORMTEXT ?????Adult Comprehensive Assessment Sections for UpdateCheck the box(es) next to the section(s) of the assessment (including addenda), which you are updating. Be sure to label all additional/updated information in your narrative with the heading of the section of the Assessment or Addendum being updated. FORMCHECKBOX Presenting Concerns FORMCHECKBOX Mental Health and Addiction Treatment Service History FORMCHECKBOX Living Situation FORMCHECKBOX Medical Providers and Physical Health Summary FORMCHECKBOX Family History FORMCHECKBOX Medication Summary FORMCHECKBOX Social Support FORMCHECKBOX Advanced Directives FORMCHECKBOX Legal Status and Legal Involvement and History FORMCHECKBOX Trauma History FORMCHECKBOX Education FORMCHECKBOX Mental Status Exam FORMCHECKBOX Employment and Meaningful Activities FORMCHECKBOX Risk Assessment FORMCHECKBOX Income/Financial Support FORMCHECKBOX Strengths/Capabilities/Resiliency FORMCHECKBOX Military Service FORMCHECKBOX Clinical Formulation FORMCHECKBOX Addictive Behavior and Substance Abuse History FORMCHECKBOX Activities of Daily Living FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Update Narrative: List each assessment section being updated with narrative explanation below it. FORMTEXT ?????Signature/Credentials (If Licensed Clinician did not obtain the information above): Date: FORMTEXT ?????ASAM Degree of Severity at Admission for the following Dimensions (SU Persons only - FORMCHECKBOX NA) DimensionIntoxication / Withdrawal PotentialBiomedical Conditions/ ComplicationsEmotional / Behavioral / CognitiveReadiness to ChangeRelapse / Continued Use PotentialRecoveryEnvironmentFamily Functioning(Youth Only) FORMTEXT ?????0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX Severe0 - FORMCHECKBOX None1 - FORMCHECKBOX Low2 - FORMCHECKBOX Moderate3 - FORMCHECKBOX High4 - FORMCHECKBOX SevereSECTION II: Diagnosis Change – This section must be completed by a qualified providerDiagnosis: : FORMCHECKBOX No Change FORMCHECKBOX If Changed Complete Below FORMCHECKBOX DSM-IV Codes FORMCHECKBOX DSM 5 Codes FORMCHECKBOX ICD-9 Codes FORMCHECKBOX ICD-10 CodesCheck Primary/Billing Diagnosis CodeNarrative Description FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Person’s Name (First / MI / Last): FORMTEXT ?????Record #: FORMTEXT ?????Person Served /Family/Guardian Expression of Service PreferencesService Preferences: FORMTEXT ????? FORMCHECKBOX No Changes Prioritized Assessed Needs (AC = Active; PD = Person Declined; DF = Deferred; RE = Referred Out) FORMCHECKBOX No Additional Recommendations Clinically IndicatedACPD*DF*RE*1. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX *Person Declined/Deferred/Referred Rationale(s) (Explain why Person Declined to work on Need Area; List rationale(s) for why Need Area(s) is/are Deferred or Referred Out below). FORMCHECKBOX None 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Further Evaluations Needed: FORMCHECKBOX None Indicated FORMCHECKBOX Psychiatric FORMCHECKBOX Visual FORMCHECKBOX Psychological FORMCHECKBOX Auditory FORMCHECKBOX Neurological FORMCHECKBOX Nutritional FORMCHECKBOX Medical FORMCHECKBOX Educational FORMCHECKBOX SU Assessment FORMCHECKBOX Vocational FORMCHECKBOX Other: FORMTEXT ?????Was Outcomes tool administered? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, specify: FORMTEXT ?????Level of Care/ Indicated Service Recommendation: FORMTEXT ????? FORMCHECKBOX No changePerson Served/Guardian/Family Response To Recommendations: FORMTEXT ????? FORMCHECKBOX Not applicableFor Annual or Interim UpdatesChange In IAP Required: FORMCHECKBOX No FORMCHECKBOX Yes (If Yes, complete the IAP Revision/Review Form to record needed changes in Goal(s),Objective(s), Interventions, Services, Frequency, and/or Provider type)Person’s Signature (Optional, if clinically appropriate) FORMTEXT ?????Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Psychiatrist/MD/DO (If required): FORMTEXT ?????Date: FORMTEXT ?????Next Appointment:Date: FORMTEXT ????? - FORMTEXT ????? Time FORMCHECKBOX am FORMCHECKBOX pmDate of ServiceProvider NumberLoc. CodePrcdr. CodeMod 1Mod2Mod3Mod4Start TimeStop TimeTotal TimeDiagnostic Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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