DBHDD



SOCIAL HISTORY AND ASSESSMENTSOURCES OF INFORMATIONInterpreter present: FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No (explain): FORMTEXT ?????Interview with the following (check only those which apply): FORMCHECKBOX Individual FORMCHECKBOX Family member(s) (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Friends (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Other persons (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Review of records (specify): FORMTEXT ????? FORMCHECKBOX Other sources (if applicable): FORMTEXT ?????Reliability of psychosocial information from individual: FORMCHECKBOX Reliable FORMCHECKBOX Questionable FORMCHECKBOX UnreliableReliability of psychosocial information from collateral sources: FORMCHECKBOX Reliable FORMCHECKBOX Questionable FORMCHECKBOX UnreliableDescribe any concerns regarding the reliability/accuracy of psychosocial information obtained from the individual and other collateral sources: FORMTEXT ?????HISTORICAL INFORMATIONCommunity Provider Name: FORMTEXT ?????Address: FORMTEXT ?????Phone Number: FORMTEXT ?????Contact Name:Relationship:Address:Phone Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????REASON FOR ADMISSION AND PRECIPITATING EVENTS: FORMTEXT ?????PSYCHIATRIC HISTORY:Original Onset of Illness & Symptomatology: FORMTEXT ?????History of Inpatient Hospitalizations, Including Dates: FORMTEXT ?????History of Outpatient Treatment Including Providers and Services Utilized: FORMTEXT ?????Individual perception related to impact of psychiatric issues on current psychosocial functioning and treatment needs: FORMTEXT ?????Family/Primary support perception related to impact of psychiatric issues on current psychosocial functioning and treatment needs: FORMTEXT ?????SUBSTANCE ABUSE HISTORY:Previous inpatient, outpatient, and residential treatment & the outcomes of treatment (including periods of sobriety): FORMTEXT ?????Individual perception related to impact of substance abuse on current psychosocial functioning and treatment needs: FORMTEXT ?????Family/Primary support perception related to impact of substance abuse on current psychosocial functioning and treatment needs: FORMTEXT ?????History of UseName of SubstanceAge at 1st UseLast UseDescription of Pattern of Use, including signs & symptoms of dependence, frequency, and route of administrationYesNoUnk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Alcohol FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cannabis FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Stimulants FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hallucinogens FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Opiates FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Barbiturates FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Benzodiazepines FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inhalants FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Nicotine FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????History of DT’s: FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes (when): FORMTEXT ?????History of Withdrawal Seizures: FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes (when): FORMTEXT ?????DEVELOPMENTAL HISTORY:Individual’s developmental history and developmental milestones (include significant prenatal events): FORMTEXT ?????Community resources/supports utilized: FORMTEXT ?????Individual perception related to impact of developmental history on current psychosocial functioning and treatment needs: FORMTEXT ?????Family/Primary support perception related to impact of developmental history on current psychosocial functioning and treatment needs: FORMTEXT ?????MEDICAL HISTORY:Individual’s current needs for medical care and any barriers to accessing care in the community: FORMTEXT ?????Current PCP/Medical Doctor (name/address/phone number): FORMTEXT ?????Does individual need linkage with PCP/Medical Doctor upon transition? FORMCHECKBOX No FORMCHECKBOX YesIndividual’s perception of impact of medical issues on current psychosocial functioning and treatment needs: FORMTEXT ?????Family/Primary support perception of impact of medical issues on current psychosocial functioning and treatment needs: FORMTEXT ?????FAMILY COMPOSITION AND HISTORY:Individual’s family of origin, including composition and dynamics impacting psychosocial functioning and treatment needs: FORMTEXT ?????SOCIAL SUPPORT:Relationship to Individual in RecoveryContact PersonTelephone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Marital Status/Significant Other: FORMCHECKBOX Single/Never Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Live-in partnerSexual Orientation: FORMCHECKBOX Heterosexual FORMCHECKBOX Bisexual FORMCHECKBOX HomosexualNumber and Ages of Children: FORMTEXT ?????Current Living Arrangements: FORMCHECKBOX Independent with Family FORMCHECKBOX Independent with Roommate/Friend FORMCHECKBOX Nursing Home FORMCHECKBOX Alone FORMCHECKBOX Host Home FORMCHECKBOX PCH FORMCHECKBOX CLA FORMCHECKBOX ITR FORMCHECKBOX IRS FORMCHECKBOX CIH FORMCHECKBOX Jail FORMCHECKBOX Homeless FORMCHECKBOX Other (specify): FORMTEXT ?????Describe Living Condition/Environment, Including who the Individual Lives with: FORMTEXT ?????Can individual return to this environment/living arrangement? FORMCHECKBOX No (explain): FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX UnknownAbuse History:Physical FORMCHECKBOX Victim FORMCHECKBOX Perpetrator FORMCHECKBOX N/AComments: FORMTEXT ?????Sexual FORMCHECKBOX Victim FORMCHECKBOX Perpetrator FORMCHECKBOX N/AComments: FORMTEXT ?????Emotional FORMCHECKBOX Victim FORMCHECKBOX Perpetrator FORMCHECKBOX N/AComments: FORMTEXT ?????Prior Treatment for Abuse: FORMTEXT ?????Is Follow-up Treatment/Referral for Abuse Indicated: FORMTEXT ?????Spiritual Life/Values:Individual’s religious preferences, practices: FORMTEXT ?????Cultural and ethnic preferences, practices: FORMTEXT ?????Any spiritual, cultural, or ethnic issues pertinent to the illness and/or treatment: FORMTEXT ?????Does the individual want spiritual counseling? FORMCHECKBOX No FORMCHECKBOX YesSpecial diet preferred? FORMCHECKBOX No FORMCHECKBOX Yes (specify): FORMTEXT ?????Discussion of any grief issues impacting current psychosocial functioning (if applicable): FORMTEXT ?????EDUCATIONAL/VOCATIONAL HISTORY:EDUCATIONAL:Highest Education Level Achieved: FORMCHECKBOX Less than High School – specify highest grade completed: FORMTEXT ????? FORMCHECKBOX High School FORMCHECKBOX GED FORMCHECKBOX Technical School FORMCHECKBOX Some College FORMCHECKBOX College FORMCHECKBOX Graduate/Professional School FORMCHECKBOX Special Education: FORMCHECKBOX No FORMCHECKBOX Yes (describe): FORMTEXT ?????If yes, did this individual receive a ;Certificate of Performance? FORMCHECKBOX No FORMCHECKBOX Yes (date): FORMTEXT ?????Special Education Certificate? FORMCHECKBOX No FORMCHECKBOX Yes (date): FORMTEXT ?????Other Diploma or Certificate? FORMCHECKBOX No FORMCHECKBOX Yes (date): FORMTEXT ?????LANGUAGE AND LEARNING NEEDS FORMCHECKBOX Limited English Proficiency (specify): FORMTEXT ????? FORMCHECKBOX Illiteracy FORMCHECKBOX Sensory Impairment (specify): FORMTEXT ????? FORMCHECKBOX None FORMCHECKBOX Other (specify): FORMTEXT ?????Describe Language and Learning Needs: FORMTEXT ?????Preferred Learning Style: FORMCHECKBOX Reading FORMCHECKBOX Watching FORMCHECKBOX Doing FORMCHECKBOX Listening FORMCHECKBOX Other (specify): FORMTEXT ?????CURRENT LEGAL STATUS AND HISTORY: FORMCHECKBOX Voluntary Status FORMCHECKBOX Involuntary Status FORMCHECKBOX Voluntary by Guardian FORMCHECKBOX Pre-Trial Evaluation FORMCHECKBOX NGRI FORMCHECKBOX IST FORMCHECKBOX Civilly Committed FORMCHECKBOX Return from Conditional Release FORMCHECKBOX Hold Order FORMCHECKBOX Mandated Outpatient Treatment FORMCHECKBOX Transfer from Another Regional Hospital History of Prior Juvenile and Adult Criminal Offenses and Outcomes (if applicable): FORMTEXT ?????Circumstances Surrounding Current Criminal Offenses (if applicable): FORMCHECKBOX Probation FORMCHECKBOX Parole FORMCHECKBOX N/AADVANCE DIRECTIVESDoes this individual have a medical advance directive? FORMCHECKBOX Yes FORMCHECKBOX NoType:Living Will FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, is a copy in the chart? FORMCHECKBOX Yes FORMCHECKBOX NoDurable POA of Healthcare FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, is a copy in the chart? FORMCHECKBOX Yes FORMCHECKBOX NoName/Address/Telephone of Agent: FORMTEXT ?????If no, is individual interested in a medical advance directive? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this individual have a legal guardian? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, is a copy in the chart? FORMCHECKBOX Yes FORMCHECKBOX NoName/Address/Telephone of Guardian FORMTEXT ?????Does this individual have a conservator? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, is a copy in the chart? FORMCHECKBOX Yes FORMCHECKBOX NoName/Address/Telephone of Conservator FORMTEXT ?????Does this individual have a General Power of Attorney? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, is a copy in the chart? FORMCHECKBOX Yes FORMCHECKBOX NoName/Address/Telephone of General POA FORMTEXT ?????FINANCIAL NEEDSSource of Income/Financial Supports: FORMCHECKBOX SSDI FORMCHECKBOX SSI FORMCHECKBOX Medicaid - # FORMTEXT ????? FORMCHECKBOX Medicare - # FORMTEXT ????? FORMCHECKBOX Medicare Part A - # FORMTEXT ????? FORMCHECKBOX Medicare Part B - # FORMTEXT ????? FORMCHECKBOX Medicare Part D - # FORMTEXT ????? FORMCHECKBOX VA Benefits FORMCHECKBOX Employment Wages FORMCHECKBOX TANF/Public Assistance FORMCHECKBOX Private Income/Family FORMCHECKBOX Benefits Pending FORMCHECKBOX Other (specify): FORMTEXT ?????Total Monthly Income: FORMTEXT ?????Is Individual payee of Check? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AName, Address, Telephone of Payee? FORMTEXT ?????Does the individual have the ability to obtain medications upon transition? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????DISCHARGE PLAN/RECOMMENDATIONSAnticipated Placement: FORMTEXT ?????Discharge Criteria for Anticipated Placement: FORMTEXT ?????Discharge Plan: FORMTEXT ?????Discharge Barriers: FORMTEXT ?????SOCIAL WORK RECOMMENDED GOALS, OBJECTIVES, AND INTERVENTIONS FOR THE INDIVIDUALIZED RECOVERY PLAN: FORMTEXT ?????SOCIAL SERVICE PROVIDER SIGNATURE FORMTEXT ?????PRINTED NAME____________________________________SIGNATURE WITH PROVIDER NUMBER_____________DATE AND TIMEACTIVITY THERAPY ASSESSMENTSOURCES OF INFORMATIONInterpreter present: FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No (explain): FORMTEXT ?????Interview with the following (check only those which apply): FORMCHECKBOX Individual FORMCHECKBOX Family member(s) (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Friends (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Other persons (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Review of records (specify): FORMTEXT ????? FORMCHECKBOX Other sources (if applicable): FORMTEXT ?????OCCUPATIONAL HISTORY:Current Employer and Position: FORMTEXT ?????How long (if applicable)? FORMTEXT ?????Work History (include volunteer work): FORMCHECKBOX Full Time FORMCHECKBOX Part Time FORMCHECKBOX Volunteer FORMCHECKBOX Supported Employment FORMCHECKBOX Sheltered Work Describe: FORMTEXT ?????Occupational/Vocational Goals, if applicable: FORMTEXT ?????Military Service: FORMCHECKBOX No military service FORMCHECKBOX Army FORMCHECKBOX Army Reserves FORMCHECKBOX Navy FORMCHECKBOX Naval Reserves FORMCHECKBOX Marine corps FORMCHECKBOX Marine corps Reserves FORMCHECKBOX Air Force FORMCHECKBOX Air Force Reserves FORMCHECKBOX Coast Guard FORMCHECKBOX National Guard Service Connected: FORMCHECKBOX Yes FORMCHECKBOX NoType of Discharge: FORMCHECKBOX Honorable FORMCHECKBOX Dishonorable FORMCHECKBOX General FORMCHECKBOX Other than honorable (describe circumstances of discharge): FORMTEXT ?????ENVIRONMENTAL AND LEISURE ASSESSMENT:ENVIRONMENTAL NEEDSDoes the individual utilize any adaptive equipment? FORMCHECKBOX No FORMCHECKBOX Yes (describe): FORMTEXT ?????Description of any additional adaptive equipment needs: FORMTEXT ?????Description of any community resources not previously discussed that are utilized by the individual: FORMTEXT ?????Description of any additional environmental needs/supports that impact the individual’s psychosocial functioning, current treatment, and transition needs: FORMTEXT ?????LEISURE AND FUNCTIONAL ABILITIESLeisure Profile (how does this individual use his/her time, what is important to him/her): FORMTEXT ?????Physical Functioning: FORMCHECKBOX No limitations FORMCHECKBOX Specific abilities, strengths, and/or limitations: FORMTEXT ?????Cognitive Functioning: FORMCHECKBOX No limitations FORMCHECKBOX Specific abilities, strengths, and/or limitations: FORMTEXT ?????Social Functioning: FORMCHECKBOX No limitations FORMCHECKBOX Specific abilities, strengths, and/or limitations: FORMTEXT ?????Life Skill Functioning (including transportation issues): FORMCHECKBOX No limitations FORMCHECKBOX Specific abilities, strengths, and/or limitations: FORMTEXT ?????Summary of Present Functional Status: FORMTEXT ?????ACTIVITY THERAPY RECOMMENDATIONS FOR ADDITIONAL ASSESSMENTS FORMCHECKBOX Vocational Assessment (specify): FORMTEXT ????? FORMCHECKBOX Physical Therapy Assessment (specify): FORMTEXT ????? FORMCHECKBOX Occupational Therapy Assessment (specify): FORMTEXT ????? FORMCHECKBOX Speech Language Pathology Assessment (specify): FORMTEXT ????? FORMCHECKBOX Assistive Technology Assessment (specify): FORMTEXT ????? FORMCHECKBOX Additional Specific Risk Assessments (specify): FORMTEXT ????? FORMCHECKBOX Other (specify): FORMTEXT ????? FORMCHECKBOX Other (specify): FORMTEXT ?????ACTIVITY THERAPY RECOMMENDED GOALS, OBJECTIVES, AND INTERVENTIONS FOR THE INDIVIDUALIZED RECOVERY PLAN: FORMTEXT ?????ACTIVITY THERAPIST SIGNATURE FORMTEXT ?????PRINTED NAME____________________________________SIGNATURE WITH PROVIDER NUMBER_____________DATE AND TIMEPSYCHOLOGY ASSESSMENTSOURCES OF INFORMATIONInterpreter present: FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No (explain): FORMTEXT ?????Interview with the following (check only those which apply): FORMCHECKBOX Individual FORMCHECKBOX Family member(s) (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Friends (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Other persons (specify name and relationship to individual): FORMTEXT ????? FORMCHECKBOX Review of records (specify): FORMTEXT ????? FORMCHECKBOX Other sources (if applicable): FORMTEXT ?????CURRENT INFORMATION:Individual’s Strengths and Preferences (Ref. Appendix 1: Strength-Based Conversations, IRP Manual): FORMTEXT ?????Individual’s Life Goals (Ref. Appendix 1: Strength-Based Conversations, IRP Manual): FORMTEXT ?????Psychosocial Issues Impacting Current Treatment and Transition Needs: FORMTEXT ?????Individual’s Stage(s) of Change (Ref. the URICA):Substance abuse FORMCHECKBOX Pre-contemplation FORMCHECKBOX Contemplation FORMCHECKBOX Preparation FORMCHECKBOX Action FORMCHECKBOX Maintenance FORMCHECKBOX Not applicableMental Illness FORMCHECKBOX Pre-contemplation FORMCHECKBOX Contemplation FORMCHECKBOX Preparation FORMCHECKBOX Action FORMCHECKBOX Maintenance Individual’s Change in Mental Status Since Admission: FORMTEXT ?????SYNTHESIS AND ANALYSIS OF PSYCHOLOGICAL ASSESSMENTS:Synthesis and Analysis: FORMTEXT ?????Recommended level of support in PSR Mall activities (check only one): FORMCHECKBOX Advanced FORMCHECKBOX Independent FORMCHECKBOX Assisted FORMCHECKBOX Supported FORMCHECKBOX Unable to determine at this time, further testing indicated (describe): FORMTEXT ?????RECOMMENDATIONS FOR ADDITIONAL ASSESSMENTS FORMCHECKBOX Violence Risk Assessment/START (required in all forensic areas) FORMCHECKBOX Intellectual Assessment (specify): FORMTEXT ????? FORMCHECKBOX Academic Assessment (specify): FORMTEXT ????? FORMCHECKBOX Personality Assessment (specify): FORMTEXT ????? FORMCHECKBOX Neuropsychological Assessment (specify): FORMTEXT ????? FORMCHECKBOX Malingering Assessment (specify): FORMTEXT ????? FORMCHECKBOX Behavioral Assessment (specify): FORMTEXT ????? FORMCHECKBOX Formal Sexual Violence Risk Assessment (specify): FORMTEXT ????? FORMCHECKBOX Other (specify): FORMTEXT ????? FORMCHECKBOX Other (specify): FORMTEXT ?????PSYCHOLOGY RECOMMENDED GOALS, OBJECTIVES, AND INTERVENTIONS FOR THE INDIVIDUALIZED RECOVERY PLAN: FORMTEXT ?????BEHAVIOR SPECIALIST SIGNATURE FORMTEXT ?????PRINTED NAME____________________________________SIGNATURE WITH PROVIDER NUMBER_____________DATE AND TIMEPSYCHOLOGIST SIGNATURE FORMTEXT ?????PRINTED NAME____________________________________SIGNATURE WITH PROVIDER NUMBER_____________DATE AND TIMERECOVERY PLANNING TEAM FACILITATOR SYNTHESISSYNTHESIS OF ALL FINDINGS AND RECOMMENDATIONS (Include discharge plan and recommendations from social work assessment.): FORMTEXT ?????INTERPRETIVE SUMMARY:Pertinent History (required): FORMTEXT ?????Predisposing Factors (optional): FORMTEXT ?????Precipitating Factors (required): FORMTEXT ?????Perpetuating Factors (optional): FORMTEXT ?????Previous Treatments & Response (optional): FORMTEXT ?????Present Status (required): FORMTEXT ?????RPT FACILITATOR SIGNATURE FORMTEXT ?????PRINTED NAME____________________________________SIGNATURE WITH PROVIDER NUMBER_____________DATE AND TIMESIGNATURES Clinicians Reviewing the Completed Integrated Psychosocial Assessment:“My signature below indicates I have reviewed the Integrated Psychosocial Assessment document”.Printed NameSignatureTitleID#DateTime FORMTEXT ?????Attending Psychiatrist FORMTEXT ????? FORMTEXT ?????Unit Nurse FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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