MENTAL HEALTH PLAN ASSESSMENT FORM
MENTAL HEALTH PLAN ASSESSMENT FORM
Every item must be completed.
Date
Provider
Phone
Provider Office Address_______________________________________________________________
Client Name _____________________________ D.O.B._____________SSN_________________ Consent to treat given by: Self Parent/Guardian Conservator
Referral Self School Probation Court CPS APS Parent/Guardian/Conservator Access Unit
Other
Living Arrangement Own House Bio Family Foster Family Group Home SNF B&C
Ethnicity________________________ Language Preferred for Services______________________
Emergency Contact
Relationship
Phone
Address______________________________________________________________________________
Presenting Problem (nature and history)
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MENTAL HEALTH PLAN ASSESSMENT FORM Risk Assessment
Current harm to self-risk N/A Ideation Intent Plan Means Describe:
History of:
Current harm to others risk N/A Ideation Intent Plan Means: Describe: History of:
Describe: (note if a particular person is at risk)
Assaultive/Combative No Yes If yes, describe:
At risk of abuse or victimization No Yes Describe:
Have all mandated reporting requirements been met? Yes, by this Provider Yes, by : No (Explain) Other: Client Strengths
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MENTAL HEALTH PLAN ASSESSMENT FORM
Client Name:
Culture/Diversity: Assess unique aspects of the client, including culture, background, and sexual orientation, that are important for understanding and engaging the client and for care planning. Preferred language for receiving our services:
Culture client most identifies with: Problems client has had because his/her cultural background: None
Sexual orientation issues: None Support/ involvement of family in client's life:
Desire of client involvement of family or others in treatment:
Desires
Psychiatric History (Medication(s) and dosage (current))
Medication(s) (past): History of Mental Illness in Family No Yes If yes, describe: Prior Hospitalization(s) No Yes If yes, when, where Prior Outpatient Treatment No Yes If yes, when and with whom:
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Client Name:
MENTAL HEALTH PLAN ASSESSMENT FORM
Medical History Health Problems (current) No Yes If yes, describe:
Height:
Weight :
Sleep Disturbance No Yes If yes, describe:
(Mandatory if client is a MINOR)
Appetite Too Little Too Much Weight gain:
lbs. Weight Loss:
lbs.
Disability Developmental Physical Cognitive Describe:
Allergies No Yes Describe:
Adverse response to medications No Yes If yes, describe:
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MENTAL HEALTH PLAN ASSESSMENT FORM
Substance Use/ Abuse
No Use
Nicotine
Caffeine
Alcohol
Marijuana
Amphetamines
Hallucinogens
Cocaine/Crack
Heroin
Prescription Meds
Other:
Frequency
Amount
Last Use
Mental Status Appearance: Orientation: Speech: Thought Process:
Thought Content: Perceptual Process:
Insight: Judgment: Mood:
Affect: Memory:
Estimated Intellectual Functioning: Cognitive Deficits:
Clean Disheveled Person Situation
Well-groomed
Inappropriate clothing
Place
Disoriented
Dirty Time
Organized/Clear Slowed Organized Thought Blocking Poor Concentration Normal Other Normal
Coherent Mumbling Coherent Flight of Ideas Obsessive Delusional
Rapid Tangential
Grandiose
Auditory hallucinations
Visual hallucinations Other
Good None Good None
Average Average
Poor Poor
Normal Elevated Anxious
Hopeless Labile Sad
Irritable Depressed Manic
Appropriate Flat Intact Recent Memory
Problem Average
Inappropriate
Blunted
Tearful
Immediate Memory Problem
Remote Memory
Below Average Above Average
None
Cognitive Deficits Present
Concentration Deficits Present
REV. 3. 2016
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