Adult Diagnostic Assessment



|Person’s Name (First MI Last): Mary M. Chase |Record #: 1234 |Date of Admission: 04/14/09 |

|Organization Name: Outpatient Services of Massachusetts |DOB: 09/19/96 |Gender: Male Female |

| | |Transgender |

|Presenting Concerns (In Person’s Served/Family’s Own Words) |

|Referral Source and Reason for Referral: Mary is being referred at this time by her school adjustment counselor following concerns that Mary appears "worried and|

|distracted" throughout the school day. The school adjustment counselor in collaboration with Mary's mother, are hoping that outpatient therapy will help them to |

|understand "what is going on" and how they can support Mary. |

|What Occurred to Cause the Person to Seek Services Now (Note Symptoms, Behavioral and Functioning Needs): Mary's adjustment counselor reports that Mary is |

|"seeming anxious all the time" and "worried about things". Mary's mother notes that she has noticed Mary does not want to be away from home and has been having|

|a lot of difficulty falling asleep at night. This is making it hard for Mary to get up in the morning and to get ready in time for school. She has been late |

|to school four out of the past ten school days. The referral is being made now because Mary has also begun to report frequent headaches and stomach aches |

|throughout the school week and at least three days out of each week Mary visits the school nurse and calls her mother to see if she can come home. This makes it|

|difficult for Mary to focus on and finish her school work. In addition, Mary's mother notes that next month is the one year anniversary of Mary's father's death|

|due to cardiac arrest and that Mary has been talking about missing her father daily, usually as she is trying to fall asleep. |

|Custody (If more than one parent/guardian has custody, check all boxes that apply to indicate sole or joint legal and/or physical custody) |

| Self: |Person is 18 yrs. Or Older Mature Minor (16 – 18 yrs. Old) |

| Parent / Guardian 1: |Name: |Joan Chase | Legal Custody | Physical Custody |

| Parent / Guardian 2: |Name: |      | Legal Custody | Physical Custody |

| DCF |Caseworker Name: |      |

| Other (Describe):       |

|Is there a need for Legal Guardian? Yes No ; If yes, complete Legal Status Addendum |

|Rep Payee? Yes No |

|Conservatorship? Yes No |

|Living Situation |

|What is the person’s current living situation? (check one) |

|Person’s Home: Rent Own |

|Residential Care/Treatment Facility: Hospital Temporary Housing Residential Program Nursing/Rest Home Supportive Housing |

|Other: |

|Friend’s Home Relative’s/Guardian’s Home Foster Care Home Respite Care Jail/Prison |

|Homeless living with friend Homeless in shelter/No residence Other:      |

|Contact name and phone number: Joan Chace (mother) 978-922-4789 |

| |

|At Risk of Losing Current Housing Yes No Satisfied with Current Living Situation Yes No |

|Comments: The family has been renting their apt. for the past 5 years and have a good relationship with the landlord |

|FAMILY ( Genogram Attached / Ecomap Attached) |

|Household Members (Name) |Relationship to Person Served |Age |

| Joan | Mother |38 |

| Mary | Person Served |12 |

|       |       |      |

|       |       |      |

|       |       |      |

|Street Address (if different from the person’s served address listed on Personal Information Form):       |

|Significant Family Members/ |Relationship to Person Served |Age |

|Others not listed above | | |

| Elisabeth | Aunt |42 |

|       |       |      |

|       |       |      |

|       |       |      |

|       |       |      |

|Significant History Regarding Family Functioning: Mary's father passed away suddenly last year at this time. Mary's maternal aunt, Elisabeth, supported Mary and|

|her mother during this time by staying with them and assisting them with shopping, rides, and support Mary describes her relationship with her mother as "really|

|close". |

|Current Status of Family Functioning (If CANS Assessment has been completed check here, if not describe below. If billing DPH complete GAIN instrument):       |

|SOCIAL FUNCTIONING |

|Significant History Regarding Social Functioning: Prior to this school year, Mary was involved with many afterschool programs and clubs including drama and the |

|school newspaper. She describes herself as "shy" with people she doesn't know, but once she gets to know them she feels able to open up. Mary reports that she |

|has many friends at school and one best friend at school who also is a neighbor. Until about a month ago, Mary said she would "hang out" with this friend every |

|single day afterschool and they would play in the woods nearby. Mary said she also likes the people who she has gotten to know through her 4-H club including |

|the other kids as well as the two leaders. Mary's mother added that Mary has a "special gift" of making friends with people of every age, stating that little |

|kids are "drawn to her" and adults find her engaging to talk with and very funny. |

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|Current Status of Social Functioning (If CANS Assessment has been completed check here, if not describe below):       |

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|MEDICAL/PHYSICAL |

|Physical Health Summary OR Refer to Attached Physical Health Assessment |

|Allergies: No Known Allergies |

|Food:       Medication:       Environmental: seasonal allergies to pollen |

|Significant History Regarding Physical Health Reported (Include immunization status, prenatal exposure to alcohol and drugs): Mary has all necessary vaccinations|

|and there is no reported history of prenatal exposure to alcohol or drugs. Stomach and headaches began to happen once or twice a week beginning about a year ago|

|around the time of her father's death. About a month ago, the headaches and stomach aches became more frequent, occurring about three or four times a week |

|usually on school days. |

|Current Status of Medical/Physical Functioning (If CANS Assessment has been completed check here, if not describe below):       |

|Primary Care Provider and Dentist Name and |Address |Tel Number |Fax |Date of Last Exam |

|Credentials | | | | |

|Dr. Livestrong |131 Main Street |888-233-5758 |888-233-5759 |12/03/08 |

|Dr. Cleanteeth |78 Water Street |978-576-9800 |978-578-9811 |Mother doesn't recall |

|DEVELOPMENTAL |

|Significant History Regarding Developmental Functioning Mary's mother reports that Mary met her developmental milestones of walking and talking on target, but was|

|slow to talk around others outside the home and it wasn't until first grade or so that Mary "seemed at ease" talking with others. Mary's mother reports that Mary|

|attended Head Start and that the teacher always said Mary "has great fine motor skills" and could cut with scissors and draw before many of her peers. |

| |

|Current Status of Developmental Functioning (If CANS Assessment has been completed check here, if not describe below):       |

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|SELF CARE |

|Significant History Regarding Self Care: Mary and her mother agreed that overall, Mary is able to care for herself well and that she enjoys picking out her |

|clothes and prides herself on having no cavities because she has always brushed and flossed regularly. Mary's mother indicated that one issue of self-care, |

|bathing/showering, has historically been "an issue". Mary shared that she knows how to bathe and knows that she should do it more often, but she just doesn't |

|"want to". When Mary's mother reminds her to bathe or asks her to take a shower, Mary often gets upset and cries. Neither Mary or her mother had a sense of |

|what was underlying this issue, but said they do talk about it a lot and that they have worked out a compromise of Mary washing daily with a wash cloth and |

|showering (including washing her hair) at least every three days. Mary's mother reports that it is still "always a fight". Mary and her mother were both |

|interested in talking about this issue more. |

|Current Status of Self Care including assistive technology and special communication needs. Include ability to self-preserve (If CANS Assessment has been |

|completed check here, if not describe below):       |

| |

|COMMUNITY |

|Significant History Regarding Community Functioning: Mary is a member of 4-H and participates in community activities through that club. She is a "rule follower"|

|according to her mother. |

| |

|Current Status of Community Functioning (If CANS Assessment has been completed check here, if not describe below):       |

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|EDUCATION |

|Learning Impairments |

|Significant History Regarding Learning Impairments: Mary has no known learning impairments. |

| |

|Current Status of Learning Impairments: (If CANS Assessment has been completed check here, if not describe below):       |

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|School Behavior |

|Significant History Regarding School Behavior: Mary has a history of being quiet in class and not getting into any trouble. Mother reports that Mary has never |

|received a detention and only had to miss recess once due to forgetting her homework. |

| |

|Current Status of School Behavior: (If CANS Assessment has been completed check here, if not describe below):       |

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|School Achievement |

|Significant History Regarding School Achievement: Mary historically has received A's and B's. Following her father's death, the school and Mary's mother noticed |

|that the grades fell and were usually C's. |

| |

|Current Status of School Achievement: (If CANS Assessment has been completed check here, if not describe below):       |

| |

|School Attendance |

|Significant History Regarding School Attendance: Mary has historically attended school regularly with missed days due to "doctors appointments or things like |

|that". Following her father's death last year, Mary stayed out three days but then had a very hard time returning to school. Mary cried each morning as she got|

|ready and would state her stomach hurt. Her mother wondered if she might have needed more time off. Over the past three months, complaints of stomache aches and|

|headaches, as well as Mary feeling tired due to not sleeping well, started to get the in way of Mary being able to get up and out of bed in order to be ready for |

|school causing her to be late. The school has been supportive in working with Mary and her mother on some plans to help her to get to school on time. |

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|Current Status of School Attendance: (If CANS Assessment has been completed check here, if not describe below):       |

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|BEHAVIORAL/EMOTIONAL NEEDS |

|Significant History Regarding Behavioral/Emotional Needs: Mary "always struggled" with her worries according to her mother, but they worsened following her |

|father's death. Mary's mother reports that she used to help Mary by giving her some things of hers to wear or bring to school or that she told her to pray about |

|her worries. Mary reports that she thinks a lot about fears that she has but doesn't like to tell others about them. Mary descibed thinking about her father a |

|lot, particularly as she is trying to fall asleep at night. |

|Current Status of Behavioral/Emotional Needs(If CANS Assessment has been completed check here, if not describe below):       |

|Needs (check all that apply): |Describe All Needs Checked: |

| Psychosis |      |

| Impulsivity/Hyperactivity |      |

| Depression |      |

| Anxiety |      |

| Oppositional |      |

| Conduct |      |

| Adjustment to Trauma |      |

| Emotional Control |      |

| Eating Disturbance |      |

| Other (Describe): |      |

|CHILD RISK BEHAVIORS |

|Significant History of Risk Behaviors (check all that apply): Mary has no history of risk behaviors |

|Current Status of Risk Behaviors: (If CANS Assessment has been completed check here, if not describe below):       |

|Needs (check all that apply): |Describe All Behaviors Checked: |

| Suicide |      |

| Mutilation |      |

| Other/Self Harm |      |

| Danger to Others |      |

| Sexual Aggression |      |

| Runaway |      |

| Delinquent Behavior |      |

| Poor Judgment |      |

| Fire Setting |      |

| Social Behavior |      |

| Gambling: |      |

| Bullying |      |

| Other (Describe) |      |

|CHILD STRENGTHS |

|Family |

|Significant History Regarding Family Strengths: Mary gets along well with her mother and aunt and is very thankful to her aunt for "being there" when her father |

|passed away. Mary said it was her aunt who "kept her mother going." Mary also thinks that her mother's good relationships with other people like her boss at |

|work and their landlord has helped their family. Mary joked that her mom's home-baked cookies are also a strength. Both Mary and her mother then agreed that |

|their shared sense of humor is a strength, particularly when either one of them is feeling sad or down. |

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|Current Status of Family Strengths: (If CANS Assessment has been completed check here, if not describe below):       |

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|Interpersonal Relationships |

|Significant Interpersonal History: Mary has a history of being able to make and maintain friendships. Mary's mother says that Mary's friends seem to "really |

|care" about Mary. Mary's shyness sometimes impacts her confidence in starting up conversations with people she doesn't know well, but her mother added that Mary |

|has "very good manners" and "doesn't seem as anxious on the outside as she says she feels on the inside". |

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|Current Status of Interpersonal Relationships: (If CANS Assessment has been completed check here, if not describe below):       |

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|Attitude of Optimism |

|Significant History Regarding Attitude of Optimism: Mary said she believes in the "glass half full" but is afraid to be too confident about good things happening|

|because she doesn't want to "jinx" them. |

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|Current Status of Attitude of Optimism: (If CANS Assessment has been completed check here, if not describe below):       |

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|Educational |

|Significant History Regarding Educational Strengths: Mary is able to get A's and B's and generally has enjoyed learning both in and out of school. She loves to |

|read and write and also loves exploring and learning about animals and nature. Mary likes to learn by doing and enjoys school projects that involve making |

|things. |

|Current Status of Educational Strengths: (If CANS Assessment has been completed check here, if not describe below):       |

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|Vocational |

|Significant History of Vocational Strengths: Mary has explored likes and dislikes in her 4-H club and says she already knows she would like to work with animals |

|when she is older. |

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|Current Status of Vocational Strengths: (If CANS Assessment has been completed check here, if not describe below):       |

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|Talents and Interests |

|Significant History of Talents and Interests: Mary is interested in all animals, but particularly in birds. She loves to watch the birds and also go on hikes in |

|the woods. Mary enjoys drawing and creating things. Mary also enjoys reading and writing. |

| |

|Current Status of Talents and Interests: (If CANS Assessment has been completed check here, if not describe below):       |

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|Spiritual and Religious |

|Significant History of Spiritual/Religious Strengths: Mary and her mother attend a local non-denominational church together "off and on". Mary's mother would |

|like for them to be more involved, but they both say they are usually "so busy" that they miss the services. Mary reports she has always prayed when she feels |

|worried about something and believes her father is in heaven. |

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|Current Status of Spiritual/Religious Strengths: (If CANS Assessment has been completed check here, if not describe below):       |

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|Community Life |

|Significant History of Community Life Strengths: |

|Current Status of Community Life Strengths: (If CANS Assessment has been completed check here, if not describe below):       |

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|Resiliency |

|Significant History of Resiliency: Mary has managed to "focus on living" following her father's death and her mother reports that this attitude has helped her |

|out a lot. Mary is able to describe the things about herself that she views as "strengths" and feels she uses them. Mary did say that sometimes her fears and |

|worry get in the way of her doing all the things she knows she can do and wants to do. |

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|Current Status of Resiliency: (If CANS Assessment has been completed check here, if not describe below):       |

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|CHILD ACCULTURATION |

|Language |

|Significant History Regarding Language: Mary and her family members all speak English and there is no significant history regarding any language or acculturation |

|issues. |

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|Current Status Regarding Language: (If CANS Assessment has been completed check here, if not describe below):       |

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|Cultural Identity |

|Significant History of Cultural Identity: Mary has always been proud of her roots and she and her mother state that they try to maintain the things that were |

|"from her dad's side", which is predominantly Italian. Mary was eager to list all of the other cultures to which she and her family members belong including |

|Irish, English, Italian, and Portuguese. |

| |

|Current Status of of Cultural Identity: (If CANS Assessment has been completed check here, if not describe below):       |

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|Cultural Ritual |

|Significant History Regarding Cultural Ritual: Mary reports it is important to her to keep doing the things that the family did when her father was still alive. |

|She noted specific traditions related to holidays and food that remind her of her Dad. Mary also said she wishes that she and her mother kept in better touch |

|with her father's family so that other traditions could be maintained. |

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|Current Status of Cultural Ritual: (If CANS Assessment has been completed check here, if not describe below):       |

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|Cultural Stress |

|Significant History Regarding Cultural Stress: Mary and her mother report no significant stress regarding culture. |

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|Current Status of Cultural Stress: (If CANS Assessment has been completed check here, if not describe below):       |

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|TRANSITION TO ADULTHOOD Not clinically indicated |

|Independent Living |

|Significant History Regarding Independent Living:       |

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|Current Status Regarding Independent Living: (If CANS Assessment has been completed check here, if not describe below):       |

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|Transportation |

|Significant History of Transportation: Mary and her mother use a car that had been Mary's father's before he passed away. Mary's mother reports the car is |

|"fickle" and sometimes they have trouble when they go far. Mary's mother reports this has made travel and making plans difficult. Both Mary and her mother |

|shared that they have a neighbor who will often ask if they need a ride or provide them with rides when the car isn't working. |

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|Current Status of Transportation: (If CANS Assessment has been completed check here, if not describe below):       |

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|Parenting Roles |

|Significant History Regarding Parenting Roles: Mary's mother said she has struggled "trying to be both a mom and a dad" and Mary responded by saying her mom is |

|"the best mom ever". Mary's mother had to return to work after Mary's father passed away but feels as though she has been able to manage her parenting |

|responsibilities "very well considering the challenges". |

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|Current Status of Parenting Roles: (If CANS Assessment has been completed check here, if not describe below):       |

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|Personality Disorder |

|Significant History Regarding Personality Disorder: No significant history regarding pesonality disorder reported. |

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|Current Status of Personality Disorder: (If CANS Assessment has been completed check here, if not describe below):       |

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|Intimate Relations |

|Significant History Regarding Intimate Relations: Mary giggled during discussion of this topic and said she "knows all about the birds and the bees". Mary did |

|state that some of her friends have begun to talk about liking people and "stuff like that", but that she is not "ready for that yet". |

|Current Status Regarding Intimate Relations: (If CANS Assessment has been completed check here, if not describe below):       |

| |

|Medication Adherence |

|Significant History of Medication Adherence: Mary takes over the counter medicines to help with her headaches and stomache aches. She and her mother also use |

|chomomile tea or peppermint tea to try to "calm down" at night before bed. Mary's mother indicated that sometimes she has used cough or allergy medicine for Mary|

|if she gets too upset and can't fall asleep. |

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|Current Status of Medication Adherence: (If CANS Assessment has been completed check here, if not describe below):       |

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|Educational Attainment |

|Significant History Regarding Educational Attainment: Mary has reached her educational goals historically including having overall A's and B's and making the |

|honor roll. |

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|Current Status of Educational Attainment: (If CANS Assessment has been completed check here, if not describe below):       |

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|Victimization |

|Significant History Regarding Victimization: Mary does not feel as though she has been victimized in any way and mother agreed. |

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|Current Status of Victimization: (If CANS Assessment has been completed check here, if not describe below):       |

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|Substance Use / Addictive Behavior History |

|Does person report a history of, or current, substance use or other addictive behavior concerns? |

|No (Skip to MH Service History section) |

|Yes;. If substance use/addictive behavior screening NOT completed (e.g., CAGE, GAIN, etc.), please complete and attach SU/Addictive Behavior History Addendum. |

|Check other assessments completed: GAIN CANS or ESM/BSAS Other: Treatment Outcome Package |

|Mental Health Service History |

|None Reported - If None Reported, skip to the Health Summary section |

|Document services used: Residential/Supported Housing Assertive Community Treatment Outpatient |

|Inpatient Day Treatment/Rehab/Clubhouse Other:       |

|Type of Service |Dates of Service |Reason |Name of Provider/Agency: |Completed |

|      |      |      |      |Yes No |

|      |      |      |      |Yes No |

|      |      |      |      |Yes No |

|      |      |      |      |Yes No |

|      |      |      |      |Yes No |

|      |      |      |      |Yes No |

|Comments on Effectiveness of Mental Health Services Received (include efficacy of current/historical psychiatric interventions; use of crisis services):       |

| Past/Current Diagnoses: Not known by person served /       |

|Medication Information (Include Non-Psych Meds/Prescription/ OTC/ Herbal) None Reported |

|Medication |Rationale/ Condition|Dosage / Route / |Reported |Adherence |Prescriber |

| | |Frequency |Side-effects |WA = With Assistance | |

|Ibuprophen |Headaches |1 - 3 daily/oral |stomach upset | No Yes WA |(OTC) |

|chamomile or peppermint tea |to help "calm down" |1 cup/oral/ 3-5 |None | No Yes WA |(OTC/Herbal) |

| | |nights a week | | | |

|Antihistimine |to fall asleep |1 tablet/oral/ |groggy in the morning | No Yes WA |(OTC) |

| | |periodic (about 1x | | | |

| | |monthly) | | | |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|      |      |      |      | No Yes WA |      |

|Comments on Medications: (Include what medications have worked well previously, any adverse side effects, why person doesn’t take meds as prescribed and/or which |

|one(s) the person would like to avoid taking in the future.): Ibuprophen is used regularly and sometimes causes stomache upset. When used, one to three tablets |

|are taken and more information will be gathered to determine how often ibuprophen is being used. Mary said that it usually is helpful in getting rid of headaches |

|but sometimes makes her stomach aches worse. Mary's mother said she's resorted to using allergy medicine/antihistimine when Mary is "very upset and can't fall |

|asleep". She said she knows she probably should not use this medicine in this way but just doesn't know what else to do. Mary likes to use herbal tea to deal |

|with feeling "upset" or when she wants to try to "calm down" at the end of a day. Mary and her mother both reported being hesitant about trying prescription |

|medications but think that it might be worth looking into for the short term. |

|Legal Status and Legal Involvement and History |

|Does the person have a history of, or current involvement with the legal system (i.e., legal charges)? No Yes; If yes, Please complete and attach the Legal |

|Involvement and History Addendum |

|Trauma History |

|Does person report a history of trauma? No Yes |

|Does person report history/current family/significant other, household, and/or environmental violence, abuse or neglect or exploitation? No Yes If yes, complete|

|the CA Trauma History Addendum |

|Mental Status Exam – (WNL = Within Normal Limits) (**) – If Checked, Risk Assessment is Required |

|Appearance: | WNL | Neat and appropriate | Physically unkempt |Clothing: | WNL Disheveled |

| | | | | |Out of the ordinary |

|Eye Contact: | WNL | Avoidant Intense | Intermittent | | |

|Build: | WNL | Thin Overweight | Short Tall |

|Posture: | WNL | Slumped Rigid, tense | Atypical |

|Body Movement: WNL Accelerated Slowed Peculiar Restless Agitated |

|Behavior: Relaxed | Cooperative | Uncooperative Overly compliant | Withdrawn | Sleepy |

| Nervous / Anxious | Restless | Silly Avoidant / Guarded / Suspicious | Preoccupied | Demanding |

| Controlling Unable to perceive pleasure Provocative Hyperactive Impulsive Agitated | Angry |

| Assaultive Aggressive Compulsive |

|Speech: WNL Mute | Over-talkative Slowed Slurred Stammer Rapid Pressured |

|Loud Soft Clear |Repetitive |

|Emotional State-Mood: | WNL Lack of feelings Blunted, unvarying Euphoric, elated | Tranquil |

|Anger Hostility |Irritable Fear, apprehension Depressed, sadness |Anxious |

|Emotional State-Affect: WNL Constricted Flat Inappropriate Changeable Full |

|Panic attacks or symptoms Sleep disturbance Appetite disturbance |

|Facial Expression: WNL | Anxiety, fear, apprehension Sadness, depression Anger, hostility, irritability |

|Expressionless Unvarying |Inappropriate Elated |

|Perception: | WNL | Illusions | Depersonalization | De-realization | Re-experiencing |

|Hallucinations - |Auditory |Visual |Olfactory Gustatory |Tactile |Command** |

|Thought Content: WNL | | | |

| Delusions - None reported | Grandiose Persecutory | Somatic | Illogical | Chaotic Religious |

| Other Content - Preoccupied | Obsessional Guarded | Phobic | Suspicious | Guilty |

| Thought broadcasting | Thought insertion Ideas of reference |

| Self Abuse Thoughts- | None reported Cutting** | Burning** | Other self mutilation** |

| Suicidal Thoughts - | None reported Passive SI** Intent** | Plan** | Means** |

| Aggressive Thoughts - | None reported Intent** | Plan** | Means** |

|Thought Process WNL | | Incoherent | Circumstantial | Decreased thought flow |

| Blocked Flight of ideas | Loose | Racing | Increased thought flow | Concrete Tangential |

|Intellectual Functioning | WNL | Lessened fund of common knowledge Short attention span |

|Impaired concentration | | |

|Intelligence Estimate - | | |

| | Impaired calculation ability |

| | MR | Borderline | Average | Above average No formal testing |

|Orientation: WNL Disoriented to: | Person | Time | Place |

|Memory: WNL Impaired: Immediate recall Recent memory Remote memory |

|Insight: WNL Difficulty acknowledging presence of psychological problems |

|Mostly blames other for problems Thinks he/she has no problems |

|Judgment: WNL Impaired Ability to Make Reasonable Decisions: Some Severe** |

|Past Attempts to Harm Self or Others: None Reported Self** Others** |

|Comment:       |

|Comments: Mary was able to engage in conversation with some break in eye contact when certain topics such as her father or showering/bathing were discussed. Mary's|

|voice was quiet at times but as the session progressed, she spoke at a louder tone and laughed and smiled. Mary played with her hair, winding it around her finger |

|and jiggled her leg frequently. She was eager to talk and wanted to answer questions for herself or add to her mother's responses to questions. |

|Summary of Assessed Needs Including Functional Domains |

|( |Check All Current Need Areas |As evidenced by: |Person Served Desires Change |

| | | |Now?: |

|Activities of Daily Living |

|If checked, agency’s functional assessment should be completed |

| |Education/Employment: |      | Yes No |

| |Housing Stability: |      | Yes No |

| |Money Management: |      | Yes No |

| |Personal Care Skills (Includes Grooming & |Crying and not wanting to follow through when prompted to bathe/shower | Yes No |

| |Dress): | | |

| |Exercise |      | Yes No |

| |Transportation |Potential needs due to unreliable car | Yes No |

| |Problem Solving Skills: |      | Yes No |

| |Time Management: |      | Yes No |

|Addictive Behaviors |

| | Substance Use/Addiction: |      | Yes No |

| | Other Addictive Behaviors (food, gambling, |      | Yes No |

| |exercise, sex, etc.): | | |

|Behavior Management |

| |Anger/Aggression: |      | Yes No |

| | Antisocial Behaviors: |      | Yes No |

| |Lack of Assertiveness: |      | Yes No |

| | Impulsivity: |      | Yes No |

| |Legal Problems: |      | Yes No |

| |Oppositional Behaviors: |      | Yes No |

|Family and Social Support |

| |Communication Skills: |      | Yes No |

| |Community Integration: |      | Yes No |

| | Dependency Issues: |      | Yes No |

| | Family education: (Family education must be |      | Yes No |

| |directed to the exclusive well being of the | | |

| |person served): | | |

| |Family Relationships: |      | Yes No |

| |Peer / Personal Support Network: |      | Yes No |

| |Recreation/Leisure Skills: |      | Yes No |

| |Social/Interpersonal Skills: |      | Yes No |

|Mental Health/Illness Management |

| |Anxiety: |Daily worry and feeling scared, not wanting to be away from home or | Yes No |

| | |mother, wanting to return home once at school, racing thoughts at bed time| |

| |Coping/ Symptom Management Skills: |      | Yes No |

| |Cognitive Problems: |      | Yes No |

| |Compulsive Behavior: |      | Yes No |

| |Depression/Sadness: |      | Yes No |

| |Dissociation: |      | Yes No |

| |Disturbed Reality (Hallucinations): |      | Yes No |

| |Disturbed Reality (Delusions): |      | Yes No |

| |Gender Identity: |      | Yes No |

| |Grief/Bereavement: |Mary and her mother still struggle as a family with sadness and coping in | Yes No |

| | |the aftermath of Mary's father's death. | |

| |Hyperactivity/Hypomania: |      | Yes No |

| |Mood Swings: |      | Yes No |

| |Obsessions: |      | Yes No |

| |Somatic Problems: |Mary experiences headaches and stomach aches four to five times a week. | Yes No |

| |Stress Management: |      | Yes No |

| |Trauma: |      | Yes No |

|Physical Health |

|( |Check All Current Problem Areas |As evidenced by: |Person Served Desires Change |

| | | |Now?: |

| |Health Practices: |      | Yes No |

| |Diet/Nutrition: |      | Yes No |

| |Pain Management: |      | Yes No |

| |Sexual Problems: |      | Yes No |

| |Sleep Problems: |Mary has trouble falling asleep some nights and wakes up tired | Yes No |

|Risk/Safety |

| |High Risk Behaviors: |      | Yes No |

| |Suicidal Ideation: |      | Yes No |

| |Homicidal Ideation: |      | Yes No |

| |Safety/Self-Preservation Skills: |      | Yes No |

|Other |

| |Other:       |      | Yes No |

| |Other:       |      | Yes No |

| |Other:       |      | Yes No |

|Service Preferences: Mary and her mother are interested in individual therapy for Mary with some family sessions and consultation with the school adjustment |

|counselor and primary care physician. They would like to learn about other resources in the community or things that would be supportive of the process. |

| |

| |

| |

| |

| |

|Clinical Formulation – Interpretative Summary |

|This Clinical Summary is Based Upon Information Provided by (check all that apply): |

| Person Served Parent(s) | Guardian(s) | Family/Friend Physician Records |

|Law enforcement Service provider |School personnel |Other: Child and Adolescent Needs and Strengths (CANS) |

|Interpretive Summary: What in your clinical judgment are the issue(s), the factors that led to the issues, and your plan to address the issues? Include all |

|assessment sources. |

|Mary is a twelve year old girl, willingly entering outpatient therapy following a recent worsening of anxiety symptoms and increased concerns from the school and |

|her mother. While it seems Mary had anxious symptoms prior to a year ago, they were worsened following her father's sudden death and continue to worsen as the |

|first anniversary approaches. In addition, sleep difficulties and physical symptoms of headaches and stomach aches have emerged and are getting in the way of |

|Mary's ability to get to school on time, interact with friends, and separate from her home and mother. Mary has many strength and resiliency factors including |

|strong relationships with both peers and adults, interests, hobbies, and an optimistic outlook. Mary's sense of humor and willingness to problem solve are |

|evident and have assisted in managing stressful situations. Mary and her mother are open to trying various strategies for coping with the anxiety and other |

|issues that have emerged. The plan for addressing the issues includes individual and family therapy focused on determing more specifically what is working now |

|and what has worked in the past, adding additional strategies and skills, and pursuing a medication evaluation. In addition to Mary learning ways to manage and |

|decrease her anxious symptoms, a plan will be identified detailing ways in which her mother and the school can provide support and coaching. |

|Diagnosis: DSM Codes (or successor) ICD Codes (or successor) |

|Check |Axis |Code |Narrative Description |

|Primary | | | |

| |Axis I |300.02 |Generalized Anxiety |

| | |      |      |

| | |      |      |

| |Axis II |V71.09 |No Diagnosis |

| | |      |      |

| |Axis III |      |None |

| |Axis IV |      |      |

| |Axis V |Current GAF: 62 |Highest in Past Year GAF (If Known): 70 |

| Further Evaluations Needed: |

|None Indicated Psychiatric Psychological Neurological Medical Educational |

|Vocational Visual Auditory Nutritional SA Assessment Other:       |

|Was Outcomes tool administered? Yes No If Yes, specify: CANS assessment serves at outcome tool      |

|Prioritized Assessed Needs: |A |F/G* |PR* |D* |R* |

|A-Active, PD-Person Declined, F/G-Family/Guardian declined, | | | | | |

|D-Deferred, R-Referred Out (If person or family/guardian declined/deferred/referred out, please provide rationale) | | | | | |

|1. Increase skills and strategies for managing anxious symptoms, including referral for medication evaluation | | | | | |

|2. Improve sleep hygiene to support ability to fall asleep more easily | | | | | |

|3. Further assess needs for support related to grief/bereavement as first anniversary of father's death approaches | | | | | |

|4. Determine underlying factors contributing to aversion to showering/bathing and identify a plan to address | | | | | |

|5. Rule out any potential medical issues, which may be contributing to somatic symptoms of headaches and stomach | | | | | |

|aches | | | | | |

|6. Determine alternative options for transportation and/or addressing unreliability of car | | | | | |

|*Person or Family/Guardian Declined/Deferred/Referred Out Rationale(s) (Explain why Person or Family/Guardian Declined to work on Need Area; List rationale(s) |

|for why Need Area(s) is/are Deferred/Referred Out below).      None |

|1. Mary and her mother prefer at this time to follow up on a referral to a local support group for coping with loss and to work on this need area in that way as |

|well as through connections with their church. |

| |

|2. Mary's mother requested a referral to a local occupational therapist to explore whether or not any sensory issues are interfering with Mary's willingness to |

|shower/bathe. Mary thinks this may have something to do with it and would like to learn more. |

| |

|3. Mary will be referred back to her primary care physician to share information about somatic complaints. Consultation between the primary care physician and |

|this provider will occur. |

| |

|4. Mary's mother feels as though she can work on transportation challenges on her own, but will inform this provider if assistance in needed in the future. |

|Level of Care/ Indicated Services Recommendation: Outpatient therapy; individual and family. Consultations with school and primary care physician. |

|Will person’s family be involved with treatment Yes No. If yes, specify (include family’s response to recommendations, the involvement of family in the |

|assessment process, state agency involvement and other supports).: Mother is supportive and eager to participate in family treatment and to support Mary's |

|individual treatment |

|Provider - Print Name/Credential: |Date: |Supervisor - Print Name/Credential (if needed): |Date: |

|      |      |      |      |

|Provider Signature: |Date: |Supervisor Signature (if needed): |Date: |

|      |      |      |      |

|Person’s Signature (Optional, if clinically appropriate): |Date: |Parent/Guardian Signature (If appropriate): |Date: |

|      |      |      |      |

|MD Signature (Required For Opiate Treatment Programs); |Date: |Next Appointment: |

|Is this an interactive assessment? Yes No – |      |Date:      /     /      - Time:       am pm |

Date of ServiceProvider NumberLoc. CodePrcdr. CodeMod 1Mod2Mod3Mod4Start TimeStop TimeTotal TimeDiagnostic Code04/14/0989773811         11:0012:001 hour300.02

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