Initial Mental Health Assessment
COUNTY OF ORANGE, CALIFORNIA
HEALTH CARE AGENCY
BEHAVIORAL HEALTH SERVICES |IDENTIFICATION IMPRINT | |
|Client’s Self-Report | |
|Your Name: | |Age: | |Tod|
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|Please answer the following questions. This is to better understand more aspects of your mental health or illness. |
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|Please tell us why you are requesting mental health services, and what are your expectations? |
|Describe or List: | | |
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|Recently, or in the past have you: Describe or List |
|Had any mental or emotional symptoms? No Yes | | |
|Had a history of mental illness? No Yes | | |
|Been prescribed psychiatric medications? No Yes | | |
|Had a therapist / MH counseling? No Yes | | |
|Been in a psychiatric hospital? No Yes | | |
|Felt that you could hurt yourself or someone | | |
|else? (or is someone else hurting you?) No Yes | | |
|Tried to deal with this problem or | | |
|situation with drug or alcohol use? No Yes | | |
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|Community Functioning |
|Are you having any problems with: Describe or List |
|Your living arrangements? No Yes | | |
|Your finances or money management? No Yes | | |
|Communicating your needs to others? No Yes | | |
|Performing personal care or travel? No Yes | | |
|Work or school? No Yes | | |
|Legal problems? No Yes | | |
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|What is your current or last work / school? | | |
|What type of work do you like or do? Occupation? | | |
|What was your longest job or period of work? | | |
|What was you earliest job? | | |
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|COUNTY OF ORANGE, CALIFORNIA |IDENTIFICATION IMPRINT |
|HEALTH CARE AGENCY | |
|BEHAVIORAL HEALTH SERVICES | |
|Client’s Self-Report | |
|Medical History |
|Recently, or in the past have you: Describe or List |
|Had ALLERGIES to any medications? No Yes | | |
|Had any physical illness or symptoms? No Yes | | |
|Been prescribed medications for an illness? No Yes | | |
|Been in a medical hospital? No Yes | | |
|Had serious medical illness? No Yes | | |
|Had a primary care doctor? No Yes | | |
|Doctor’s Name and Location: | | |
|Recently, or in the past have you had: |
|Head injury or stroke? No Yes Seizures or epilepsy? No Yes Headache or back problem? No Yes |
|Numbness or tingling? No Yes Trembling/shaking? No Yes Sweating / feeling hot / hot flushes? No Yes |
|Dizziness, or fainting? No Yes High blood pressure? No Yes Palpitations / pounding heart / chest pain No Yes |
|Asthma/breathing problem? No Yes Choking or smothering No Yes Nausea, stomach or intestinal problems? No Yes |
|Unusual bleeding? No Yes Cancer? No Yes Thyroid problems or hormone imbalance? No Yes |
|Kidney / bladder problems? No Yes Sexual dysfunction? No Yes Liver problems, jaundice, or liver trouble? No Yes |
|Pregnancy? No Yes Other? No Yes Diabetes or blood sugar problems? No Yes |
|Describe: | | |
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|Family History |
|Have you had relatives or significant others who have: Describe or List |
|MENTAL illness or drug / alcohol problems? No Yes | | |
|Serious medical illness? No Yes | | |
|Supportive relationship with you? No Yes | | |
|Extremely difficult relationship with you? No Yes | | |
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|Social History |
|Have you had: Describe or List |
|Traumatic events? No Yes | | |
|History of abuse? No Yes | | |
|Issues related to sexuality? No Yes | | |
|Positive events, Achievements, Strengths? No Yes | | |
|Where and with whom did you grow up? | | |
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|CLIENT’S SIGNATURE | | |
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