Clinical Assessment



Clinical AssessmentClinician: FORMTEXT ?????Client ID #: FORMTEXT ?????Primary configuration: FORMCHECKBOX Individual FORMCHECKBOX Couple FORMCHECKBOX FamilyPrimary Language: FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Other: FORMTEXT ?????List client and significant othersAdult(s) FORMDROPDOWN Age: FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN Occupation: FORMTEXT ????? Other identifier: FORMTEXT ????? FORMDROPDOWN Age: FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN Occupation: FORMTEXT ????? Other identifier: FORMTEXT ?????Child(ren) FORMDROPDOWN Age: FORMTEXT ????? FORMDROPDOWN Grade: FORMDROPDOWN School: FORMTEXT ????? Other identifier: FORMTEXT ????? FORMDROPDOWN Age: FORMTEXT ????? FORMDROPDOWN Grade: FORMDROPDOWN School: FORMTEXT ????? Other identifier: FORMTEXT ?????Others: FORMTEXT ?????Presenting Problems FORMCHECKBOX Depression/hopelessness FORMCHECKBOX Anxiety/worry FORMCHECKBOX Anger issues FORMCHECKBOX Loss/grief FORMCHECKBOX Suicidal thoughts/attempts FORMCHECKBOX Sexual abuse/rape FORMCHECKBOX Alcohol/drug use FORMCHECKBOX Eating problems/disorders FORMCHECKBOX Job problems/unemployed FORMCHECKBOX Couple concerns FORMCHECKBOX Parent/child conflict FORMCHECKBOX Partner violence/abuse FORMCHECKBOX Divorce adjustment FORMCHECKBOX Remarriage adjustment FORMCHECKBOX Sexuality/intimacy concerns FORMCHECKBOX Major life changes FORMCHECKBOX Legal issues/probation FORMCHECKBOX Other: FORMTEXT ????? Complete for children: FORMCHECKBOX School failure/decline performance FORMCHECKBOX Truancy/runaway FORMCHECKBOX Fighting w/peers FORMCHECKBOX Hyperactivity FORMCHECKBOX Wetting/soiling clothing FORMCHECKBOX Child abuse/neglect FORMCHECKBOX Isolation/withdrawal FORMCHECKBOX Other: FORMTEXT ?????Mental Status Assessment for Identified PatientInterpersonal FORMCHECKBOX NA FORMCHECKBOX Conflict FORMCHECKBOX Enmeshment FORMCHECKBOX Isolation/avoidance FORMCHECKBOX Harassment FORMCHECKBOX Other: FORMTEXT ?????Mood FORMCHECKBOX NA FORMCHECKBOX Depressed/Sad FORMCHECKBOX Anxious FORMCHECKBOX Dysphoric FORMCHECKBOX Angry FORMCHECKBOX Irritable FORMCHECKBOX Manic FORMCHECKBOX Other: FORMTEXT ?????Affect FORMCHECKBOX NA FORMCHECKBOX Constricted FORMCHECKBOX Blunt FORMCHECKBOX Flat FORMCHECKBOX Labile FORMCHECKBOX Incongruent FORMCHECKBOX Other: FORMTEXT ?????Sleep FORMCHECKBOX NA FORMCHECKBOX Hypersomnia FORMCHECKBOX Insomnia FORMCHECKBOX Disrupted FORMCHECKBOX Nightmares FORMCHECKBOX Other: FORMTEXT ?????Eating FORMCHECKBOX NA FORMCHECKBOX Increase FORMCHECKBOX Decrease FORMCHECKBOX Anorectic restriction FORMCHECKBOX Binging FORMCHECKBOX Purging FORMCHECKBOX Other: FORMTEXT ?????Anxiety FORMCHECKBOX NA FORMCHECKBOX Chronic worry FORMCHECKBOX Panic FORMCHECKBOX Phobias FORMCHECKBOX Obsessions FORMCHECKBOX Compulsions FORMCHECKBOX Other: FORMTEXT ?????Trauma Symptoms FORMCHECKBOX NA FORMCHECKBOX Hypervigilance FORMCHECKBOX Flashbacks/Intrusive memories FORMCHECKBOX Dissociation FORMCHECKBOX Numbing FORMCHECKBOX Avoidance efforts FORMCHECKBOX Other: FORMTEXT ?????Psychotic Symptoms FORMCHECKBOX NA FORMCHECKBOX Hallucinations FORMCHECKBOX Delusions FORMCHECKBOX Paranoia FORMCHECKBOX Loose associations FORMCHECKBOX Other: FORMTEXT ?????Motor activity/Speech FORMCHECKBOX NA FORMCHECKBOX Low energy FORMCHECKBOX Hyperactive FORMCHECKBOX Agitated FORMCHECKBOX Inattentive FORMCHECKBOX Impulsive FORMCHECKBOX Pressured speech FORMCHECKBOX Slow speech FORMCHECKBOX Other: FORMTEXT ?????Thought FORMCHECKBOX NA FORMCHECKBOX Poor concentration FORMCHECKBOX Denial FORMCHECKBOX Self-blame FORMCHECKBOX Other-blame FORMCHECKBOX Ruminative FORMCHECKBOX Tangential FORMCHECKBOX Concrete FORMCHECKBOX Poor insight FORMCHECKBOX Impaired decision making FORMCHECKBOX Disoriented FORMCHECKBOX Other: FORMTEXT ?????Socio-Legal FORMCHECKBOX NA FORMCHECKBOX Disregards rules FORMCHECKBOX Defiant FORMCHECKBOX Stealing FORMCHECKBOX Lying FORMCHECKBOX Tantrums FORMCHECKBOX Arrest/incarceration FORMCHECKBOX Initiates fights FORMCHECKBOX Other: FORMTEXT ?????Other Symptoms FORMCHECKBOX NA FORMTEXT ?????Diagnosis for Identified PatientContextual Factors considered in making diagnosis: FORMCHECKBOX Age FORMCHECKBOX Gender FORMCHECKBOX Family dynamics FORMCHECKBOX Culture FORMCHECKBOX Language FORMCHECKBOX Religion FORMCHECKBOX Economic FORMCHECKBOX Immigration FORMCHECKBOX Sexual/gender orientation FORMCHECKBOX Trauma FORMCHECKBOX Dual diagnosis/comorbid FORMCHECKBOX Addiction FORMCHECKBOX Cognitive ability FORMCHECKBOX Other: FORMTEXT ?????Describe impact of identified factors on diagnosis and assessment process: FORMTEXT ?????DSM-5 CodeDiagnosis with Specifier Include V/Z/T-Codes for Psychosocial Stressors/Issues1. FORMTEXT ?????2. FORMTEXT ????? 3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ????? 3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????Medical ConsiderationsHas patient been referred for psychiatric evaluation? FORMCHECKBOX Yes FORMCHECKBOX NoHas patient agreed with referral? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAPsychometric instruments used for assessment: FORMCHECKBOX None FORMCHECKBOX Cross-cutting symptom inventories FORMCHECKBOX Other: FORMTEXT ?????Client response to diagnosis: FORMCHECKBOX Agree FORMCHECKBOX Somewhat agree FORMCHECKBOX Disagree FORMCHECKBOX Not informed for following reason: FORMTEXT ?????Current Medications (psychiatric & medical) FORMCHECKBOX NA1. FORMTEXT ?????; dose FORMTEXT ????? mg; start date: FORMTEXT ?????2. FORMTEXT ?????; dose FORMTEXT ????? mg; start date: FORMTEXT ?????3. FORMTEXT ?????; dose FORMTEXT ????? mg; start date: FORMTEXT ?????4. FORMTEXT ?????; dose FORMTEXT ????? mg; start date: FORMTEXT ?????Medical Necessity: Check all that apply FORMCHECKBOX Significant impairment FORMCHECKBOX Probability of significant impairment FORMCHECKBOX Probable developmental arrestAreas of impairment: FORMCHECKBOX Daily activities FORMCHECKBOX Social relationships FORMCHECKBOX Health FORMCHECKBOX Work/School FORMCHECKBOX Living arrangement FORMCHECKBOX Other: FORMTEXT ?????Risk and Safety Assessment for Identified PatientSuicidality FORMCHECKBOX No indication/Denies FORMCHECKBOX Active ideation FORMCHECKBOX Passive ideation FORMCHECKBOX Intent without plan FORMCHECKBOX Intent with means FORMCHECKBOX Ideation in past year FORMCHECKBOX Attempt in past year FORMCHECKBOX Family or peer history of completed suicideHomicidality FORMCHECKBOX No indication/Denies FORMCHECKBOX Active ideation FORMCHECKBOX Passive ideation FORMCHECKBOX Intent without means FORMCHECKBOX Intent with means FORMCHECKBOX Ideation in past year FORMCHECKBOX Violence past year FORMCHECKBOX History of assaulting others FORMCHECKBOX Cruelty to animalsAlcohol Abuse FORMCHECKBOX No indication/denies FORMCHECKBOX Past abuse FORMCHECKBOX Current; Freq/Amt: FORMTEXT ?????Drug Use/Abuse FORMCHECKBOX No indication/denies FORMCHECKBOX Past use FORMCHECKBOX Current drugs: FORMTEXT ?????Freq/Amt: FORMTEXT ????? FORMCHECKBOX Family/sig.other useSexual & Physical Abuse and Other Risk Factors FORMCHECKBOX Childhood abuse history: FORMCHECKBOX Sexual FORMCHECKBOX Physical FORMCHECKBOX Emotional FORMCHECKBOX Neglect FORMCHECKBOX Adult with abuse/assault in adulthood: FORMCHECKBOX Sexual FORMCHECKBOX Physical FORMCHECKBOX Current FORMCHECKBOX History of perpetrating abuse: FORMCHECKBOX Sexual FORMCHECKBOX Physical FORMCHECKBOX Emotional FORMCHECKBOX Elder/dependent adult abuse/neglect FORMCHECKBOX History of or current issues with restrictive eating, binging, and/or purging FORMCHECKBOX Cutting or other self harm: FORMCHECKBOX Current FORMCHECKBOX Past: Method: FORMTEXT ????? FORMCHECKBOX Criminal/legal history: FORMTEXT ????? FORMCHECKBOX Other trauma history: FORMTEXT ????? FORMCHECKBOX None reportedIndicators of Safety FORMCHECKBOX NA FORMCHECKBOX At least one outside support person FORMCHECKBOX Able to cite specific reasons to live or not harm FORMCHECKBOX Hopeful FORMCHECKBOX Willing to dispose of dangerous items FORMCHECKBOX Has future goals FORMCHECKBOX Willingness to reduce contact with people who make situation worse FORMCHECKBOX Willing to implement safety plan, safety interventions FORMCHECKBOX Developing set of alternatives to self/other harm FORMCHECKBOX Sustained period of safety: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Elements of Safety Plan FORMCHECKBOX NA FORMCHECKBOX Verbal no harm contract FORMCHECKBOX Written no harm contract FORMCHECKBOX Emergency contact card FORMCHECKBOX Emergency therapist/agency number FORMCHECKBOX Medication management FORMCHECKBOX Plan for contacting friends/support persons during crisis FORMCHECKBOX Specific plan of where to go during crisis FORMCHECKBOX Specific self-calming tasks to reduce risk before reach crisis level (e.g., journaling, exercising, etc.) FORMCHECKBOX Specific daily/weekly activities to reduce stressors FORMCHECKBOX Other: FORMTEXT ?????Legal/Ethical Action Taken: FORMCHECKBOX NA FORMCHECKBOX Action: FORMTEXT ?????Case ManagementCollateral ContactsHas contact been made with treating physicians or other professionals: FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX In process. Name/Notes: FORMTEXT ????? If client is involved in mental health treatment elsewhere, has contact been made? FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX In process. Name/Notes: FORMTEXT ?????Has contact been made with social worker: FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX In process. Name/Notes: FORMTEXT ????? ReferralsHas client been referred for medical assessment: FORMCHECKBOX Yes FORMCHECKBOX No evidence for need Has client been referred for social services: FORMCHECKBOX NA FORMCHECKBOX Job/training FORMCHECKBOX Welfare/Food/Housing FORMCHECKBOX Victim services FORMCHECKBOX Legal aid FORMCHECKBOX Medical FORMCHECKBOX Other: FORMTEXT ????? Has client been referred for group or other support services: FORMCHECKBOX Yes: FORMTEXT ????? FORMCHECKBOX In process FORMCHECKBOX None recommendedAre there anticipated forensic/legal processes related to treatment: FORMCHECKBOX No FORMCHECKBOX Yes; describe: FORMTEXT ?????Support NetworkClient social support network includes: FORMCHECKBOX Supportive family FORMCHECKBOX Supportive partner FORMCHECKBOX Friends FORMCHECKBOX Religious/spiritual organization FORMCHECKBOX Supportive work/social group FORMCHECKBOX Other: FORMTEXT ?????Describe anticipated effects treatment will have on others in support system (Children, partner, etc.): FORMTEXT ?????Is there anything else client will need to be successful? FORMTEXT ?????Expected Outcome and Prognosis FORMCHECKBOX Return to normal functioning FORMCHECKBOX Anticipate less than normal functioning FORMCHECKBOX Prevent deteriorationClient Sense of Hope: FORMDROPDOWN Evaluation of Assessment/Client PerspectiveHow were assessment methods adapted to client needs, including age, culture, and other diversity issues? FORMTEXT ?????Describe actual or potential areas of client-clinician agreement/disagreement related to the above assessment: FORMTEXT ?????_____________________________________________,________________ _____________Clinician Signature License/Intern Status Date_____________________________________________,________________ _____________Supervisor Signature License Date ................
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