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PROVIDERADDRESSPHONEFAXCLIENT LAST NAMECLIENT FIRST NAMEMIDDLE NAMESUFFIX (Sr., Jr.)PREFERRED LAST NAMEPREFERRED FIRST NAMED.O.B.Sex Assigned at Birth: ?Male?Female ?Intersex?Other:Gender Identity: ?Male FORMCHECKBOX Declined to State Other: ?Female FORMCHECKBOX Other?Intersex Gender Queer Transgender:?Male to Female?Female to MaleSEXUAL ORIENTATION: FORMCHECKBOX Unknown FORMCHECKBOX Heterosexual/Straight FORMCHECKBOX Lesbian FORMCHECKBOX Gay FORMCHECKBOX Bisexual FORMCHECKBOX Queer FORMCHECKBOX Gender Queer FORMCHECKBOX Questioning FORMCHECKBOX Declined to State FORMCHECKBOX Other: FORMTEXT ?????Emergency ContactRelationshipContact address (Street, City, State, Zip)Contact Phone number? Release for Emergency Contact obtained for this time period:Assessment Sources of Information (Check All that Apply): FORMCHECKBOX Client FORMCHECKBOX Family Guardian FORMCHECKBOX Hospital FORMCHECKBOX Other: FORMTEXT ?????REFERRAL Source/ REASON FOR REFERRAL/ CHIEF COMPLAINTDescribe precipitating event(s) for Referral; Current Symptoms and Behaviors (intensity, duration, onset, frequency); present/new precipitants/stressors; for episodic illnesses describe first episode, onset, precipitants, duration & Rx response; etc. FORMCHECKBOX Narrative continued in AddendumPSYCHIATRIC HEALTH HISTORYInpatient & Outpatient Treatment, Trauma & Risk Factors including S/I and H/I (If any mandatory reports filed—discuss.) FORMCHECKBOX Narrative continued in AddendumPSYCHOSOCIAL HISTORY & FUNCTIONINGInclude: Client’s Family History; Family History of mental illness, suicide, substance abuse, trauma, and neglect/abuse; Cultural factors; History of Educational, Vocational, and Income; Social & Legal or Criminal Justice; Living Situation; Income; etc FORMCHECKBOX Or, see attached MH Assessment dated: __/__/____ OR FORMCHECKBOX Also, see attached MH Assessment dated: __/__/____ FORMCHECKBOX Narrative continued in AddendumThis Section for YOUTH ONLY < 18 YRS OLD FORMCHECKBOX Or, see attached MH Assessment dated: __/__/____ OR FORMCHECKBOX Also, see attached MH Assessment dated: __/__/____LIVES WITH:First Name of others in home (children & adults)AgeRelationship FORMCHECKBOX Immediate Family FORMCHECKBOX Extended Family FORMCHECKBOX Foster Family FORMCHECKBOX OtherDESCRIBE FAMILY OF ORIGIN: FORMCHECKBOX Narrative continued in AddendumEDUCATIONCurrent School: FORMTEXT ?????Spec Ed FORMCHECKBOX YES FORMCHECKBOX NOGrade FORMTEXT ??Contact/Teacher/ Ph#: FORMTEXT ?????Active IEP/Special Assessment/Services: FORMTEXT ????? FORMCHECKBOX LD FORMCHECKBOX DD/ID FORMCHECKBOX SEDLast School Attended: FORMTEXT ?????Vocational Activities: FORMTEXT ?????YOUTH (0 – 17 YRS.) DEVELOPMENTAL HISTORY (also include any significant culturally related rites of passage, rituals, ceremonies, etc.) FORMCHECKBOX Or, see attached MH Assessment dated: __/__/____ OR FORMCHECKBOX Also, see attached MH Assessment dated: __/__/____0 – 6 yrs: Include relevant prenatal/birth/childhood information including pregnancy, developmental milestones, environmental stressors and other significant events.7 – 11 yrs: Include above and relevant latency (peer/sibling relations, extracurricular activities, delinquency, environmental stressors of other significant events).12 – 17 yrs: Include above and relevant adolescence (onset of puberty, extracurricular activities, teen parenthood, delinquency, gang involvement, and environmental stressors of other significant events). FORMCHECKBOX Narrative continued in AddendumADULTS (18+ yrs.) DEVELOPMENTAL HISTORY (also include any significant culturally related rites of passage, rituals, ceremonies, etc.) FORMCHECKBOX Or, see attached MH Assessment dated: __/__/____ OR FORMCHECKBOX Also, see attached MH Assessment dated: __/__/____Adults 19+ yrs: Include relevant: childhood (where, who reared/lived in house where grew up, important/traumatic events, school experience and performance, history of physical/sexual abuse, placement history, etc.), adolescence (school and activities, friendships/relationships, sexual experiences, traumas, leaving home, placement history, etc.), adulthood (military service, marriage/divorce, children, geographical changes, traumas, current relationship with family/significant other, etc.), and aging issues (retirement, grandchildren, support systems, sleep changes, losses, etc.). FORMCHECKBOX Narrative continued in AddendumMedical History Relevant Medical History: Indicate or check only those that are relevantGeneral Information: Respiration:Weight:General Appearance:Height:Sitting BP: Standing BP:Supine BP:Temp:Cardiovascular/Respiratory: FORMCHECKBOX Chest Pain FORMCHECKBOX Hypertension FORMCHECKBOX Hypotension FORMCHECKBOX Palpitation FORMCHECKBOX SmokingGenital/Urinary/Bladder: FORMCHECKBOX Incontinence FORMCHECKBOX Nocturia FORMCHECKBOX Urinary Tract Infection FORMCHECKBOX Retention FORMCHECKBOX UrgencyGastrointestinal/Bowel: FORMCHECKBOX Heartburn FORMCHECKBOX Diarrhea FORMCHECKBOX Constipation FORMCHECKBOX Nausea FORMCHECKBOX Vomiting FORMCHECKBOX Ulcers FORMCHECKBOX Laxative Use FORMCHECKBOX IncontinenceNervous System: FORMCHECKBOX Headaches FORMCHECKBOX Dizziness FORMCHECKBOX Seizures FORMCHECKBOX Memory FORMCHECKBOX ConcentrationMusculoskeletal: FORMCHECKBOX Back Pain FORMCHECKBOX Stiffness FORMCHECKBOX Arthritis FORMCHECKBOX Mobility/AmbulationGynecology: FORMCHECKBOX Pregnant FORMCHECKBOX Pelvic Inflam. Disease FORMCHECKBOX Menopause FORMCHECKBOX Breast FeedingLast LMP:Skin: FORMCHECKBOX Scar FORMCHECKBOX Lesion FORMCHECKBOX Lice FORMCHECKBOX Dermatitis FORMCHECKBOX CancerEndocrine: FORMCHECKBOX Diabetes FORMCHECKBOX Thyroid FORMCHECKBOX Other:Respiratory: FORMCHECKBOX Bronchitis FORMCHECKBOX Asthma FORMCHECKBOX COPD FORMCHECKBOX Other FORMCHECKBOX Others (check if relevant and describe):Other: FORMCHECKBOX Significant Accident/Injuries/Surgeries: FORMTEXT ????? FORMCHECKBOX Hospitalizations: FORMTEXT ????? FORMCHECKBOX Physical Disabilities: FORMTEXT ????? FORMCHECKBOX Chronic Illness: FORMTEXT ????? FORMCHECKBOX HIV disease: FORMTEXT ????? FORMCHECKBOX Age of Menarche and Birth Control Method: FORMTEXT ????? FORMCHECKBOX History of Head Injury: FORMCHECKBOX Cardiac screening questions (required to be documented prior to starting stimulants): FORMCHECKBOX History of cardiac diagnosis (including heart murmur): FORMCHECKBOX History of palpitations, chest pain, syncope: FORMCHECKBOX Family history of sudden death less than age 30: FORMCHECKBOX If any of the three answered yes, EKG ordered.CURRENT MEDICATIONS (include all prescribed, over the counter, and holistic/complimentary/alternative remedies):Rx NameEffectiveness/Side EffectsDosageDate StartedPrescriberCurrentPastPsychotropic Non-PsychotropicPREVIOUS MEDICATIONS (include all prescribed, over the counter, and holistic/complimentary/alternative remedies):PsychtropicNon-Psychtropic FORMCHECKBOX Medication Narrative continued in AddendumAllergies/Adverse Reactions/ Sensitivities Check if Yes FORMCHECKBOX and List FORMCHECKBOX Food FORMCHECKBOX Drugs(Rx/OTC/ILLICT) FORMCHECKBOX Unknown Allergies FORMCHECKBOX Other: FORMTEXT ?????Date of last physical exam: FORMTEXT ?????Date of last dental exam:Referral made to primary care or specialty FORMCHECKBOX NO FORMCHECKBOX YESIf yes, list: FORMTEXT ?????Providers (if known):Additional Medical Information (Describe any relevant medical conditions above): FORMCHECKBOX Narrative continued in AddendumSUBSTANCE USESUBSTANCE EXPOSURE (indicate if ever used)AGE AT FIRST USECURRENT SUBSTANCE USE/DEPENDENCE/ABUSENone/DeniesCurrentUseCurrentAbuseCurrentDependenceIn RecoveryClient-perceived Problem?ALCOHOL: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX ILLICIT DRUGS: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX OVER THE COUNTER MEDICATIONS: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX CAFFEINE (ENGERY DRINKS, SODAS, COFFEE, ETC.): FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX COMPLIMENTARY/ALTERNATIVE MEDICATIONS: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX CANNABIS: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX TOBACCO/NICOTINE: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX OTHER SUBSTANCE: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Is beneficiary receiving alcohol and drug services? FORMCHECKBOX Yes, from this provider FORMCHECKBOX Yes, from a different provider FORMCHECKBOX NOIf yes, type of alcohol and drug services: FORMCHECKBOX Residential FORMCHECKBOX Outpatient FORMCHECKBOX Community/ Support GroupCOMMENTS: Include Tox Screen results, if any. FORMCHECKBOX Narrative continued in AddendumSUD REFERRALS (From the ACBHCS SUD Treatment Referral Guide, providers/SUD/resources.htm indicate the specific referrals provided to client). FORMCHECKBOX Narrative continued in AddendumMENTAL STATUS: (Check and describe if abnormal or impaired)Appearance/Grooming: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????Behavior/Relatedness: FORMCHECKBOX Unremarkable FORMCHECKBOX Motor Agitated FORMCHECKBOX Inattentive FORMCHECKBOX Avoidant FORMCHECKBOX Impulsive FORMCHECKBOX Motor Retarded FORMCHECKBOX Hostile FORMCHECKBOX Suspicious/Guarded FORMCHECKBOX Other: FORMTEXT ?????Speech: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????Mood/Affect: FORMCHECKBOX Unremarkable FORMCHECKBOX Depressed FORMCHECKBOX Elated/Expansive FORMCHECKBOX Anxious FORMCHECKBOX Labile FORMCHECKBOX Irritable/Angry FORMCHECKBOX Other:Thought Processes: FORMCHECKBOX Unremarkable FORMCHECKBOX Concrete FORMCHECKBOX Distorted FORMCHECKBOX Disorganized FORMCHECKBOX Odd/Idiosyncratic FORMCHECKBOX Blocking FORMCHECKBOX Paucity of Content FORMCHECKBOX Circumstantial FORMCHECKBOX Tangential FORMCHECKBOX Obsessive FORMCHECKBOX Flight of Ideas FORMCHECKBOX Racing Thoughts FORMCHECKBOX Loosening of Assoc FORMCHECKBOX Other:Thought Content: FORMCHECKBOX Unremarkable FORMCHECKBOX Hallucinations FORMCHECKBOX Delusions FORMCHECKBOX Ideas of Reference FORMCHECKBOX Other FORMTEXT ?????Perceptual Content: FORMCHECKBOX Unremarkable FORMCHECKBOX Hallucinations FORMCHECKBOX Homicidal Ideation FORMCHECKBOX Paranoid Reference FORMCHECKBOX Flashbacks FORMCHECKBOX Depersonalization FORMCHECKBOX Derealization FORMCHECKBOX Dissociation FORMCHECKBOX Other: FORMTEXT ?????Fund of Knowledge: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????Orientation: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????Memory: FORMCHECKBOX UnremarkableImpaired: FORMTEXT ?????Intellect: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????Insight/Judgment: FORMCHECKBOX UnremarkableRemarkable for: FORMTEXT ?????REQUIRED: Describe Mental Status Exam abnormal/impaired findings: FORMCHECKBOX Narrative continued in AddendumCIRCLE ALL TARGETED SYMPTOMSDEPRESSION (“Sigecaps”)MANIA (“DIGFAST”)PSYCHOSISPANIC ATTACKS AUTISM SPECTRUMLow/ irritable mood >2 weeksGrandioseHallucinations/illusionsTrembling Social deficits SleepIncreased activityDelusionsPalpitations Restrictive, repetitive Interest goal-directed/high riskSelf-reference:Nausea/chills patterns of BxGuilt/WorthlessnessDecreased judgment people watching youChoking/chest painEnergyDistractible talking about youSweating ConcentrationIrritability messages from mediaFear:Appetite/weightNeed less sleepThought blocking/InsertionDying/going crazyPsychomotor slowingElevated moodDisorganization: anticipatory anxietySuicide:Speedy talking speech/behavior avoidance hopelessness/plan/accessSpeedy thoughts agoraphobiaGENERALIZED ANXIETYOBSESSIVE-COMPULSIVE DISORDERPTSDExcess worryIntrusive/persistent thoughts Experienced/witnessed eventRestless/edgyRecognized as excessive/irrationalPersistent re-experiencingEasily fatiguedRepetitive behaviors:Dreams/flashbacksMuscle tension washing/cleaningAvoidance behavior↓ sleep counting/checkingHyper-arousal:↓ concentration organizing/praying ↑ vigilance/↑ startle trauma reenactment in play SOCIAL/ SPECIFIC PHOBIAOPPOSITIONAL DEFIANT DISORDER frightening dreams w/o recognizable content Performance situations:Angry/irritable mood/ resentful fear of embarrassmentArgumentative/ actively defiantADHD Inattention fear of humiliationDeliberately annoys others Inattention criticismBlames others for his/her behavior fails to complete workSpecific phobia:Vindictive at least 2x in past 6 months easily distracted heights/crowds/animals loses necessary items Hyperactivity/ Impulsivity PANIC DISORDER EATING DISORDERS talks excessively/ blurts out Anticipatory anxietyBinging/purging/restriction/amenorrhea fidgets/ can’t remain seated/ Panic attacksPerception of body image or weight acts as if driven by a motorINDICATE ANY ADDITIONAL TARGETED SYMPTOMS NOT IDENTIFIED ABOVE:NoneMildModSevereNoneMildModSevereCognition/Memory/Thought FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Perceptual Disturbance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attention/Impulsivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Oppositional/Conduct FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Socialization/Communication FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Destructive/Assaultive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Depressive Symptoms FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Agitation/Lability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety/phobia/Panic Attack FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Somatic Disturbance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Affect Regulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX REQUIRED, describe Targeted Symptoms checked above: FORMCHECKBOX Narrative continued in AddendumFUNCTIONAL IMPAIRMENTS: NoneMildModSevereNoneMildModSevereFamily Relations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Substance Use/Abuse FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School Performance/Employment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Activities of Daily Living FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Episodes of decompensation & increase of symptoms, each of extended duration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Food/Shelter FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social/Peer Relations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Describe): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Narrative continued in AddendumREQUIRED, describe Impairments checked above:Impairment Criteria (must have one of the following): AND:Intervention Criteria (proposed INTERVENTION will….): FORMCHECKBOX Significant impairment in an important area of life function. ANDSignificantly diminish impairment FORMCHECKBOX Probability of significant deterioration in an important area of functioning.ANDPrevent significant deterioration in an important area of life functioning. FORMCHECKBOX (Under 21) Without treatment will not progress developmentally as individually appropriate.AND(Under 21) Probably allow the child to progress developmentally as individually appropriate. FORMCHECKBOX None of the above.ANDNone of the aboveDSM IV DIAGNOSIS—NOT BY HISTORY, MUST BE CURRENT DIAGNOSTIC FORMULATION Axis I-III:CodeDSM & ICD-10DescriptionCheck ONE Primary below FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Narrative continued in AddendumAxis IV Psychological and Environmental Problems which may affect diagnosis, treatment, or prognosis. Primary Problem#: FORMTEXT ?????. Check ALL that apply: FORMCHECKBOX Primary support group FORMCHECKBOX Social environment FORMCHECKBOX Education FORMCHECKBOX Occupational FORMCHECKBOX Housing FORMCHECKBOX Economics FORMCHECKBOX Access to health care FORMCHECKBOX Involve with legal sys. FORMCHECKBOX Other psychosocial/environmental FORMCHECKBOX Inadequate informationAxis VCurrent GAF: FORMTEXT ?????Diagnosis est. by: FORMTEXT ?????On date: FORMTEXT ?????INITIAL PLAN (MEDICATION PRESCRIBED/LABS ORDERED/ETC.)My Signature below acknowledges having read and endorsed any prior MH Assessment referenced in this Psychiatric Assessment. FORMCHECKBOX Narrative continued in AddendumPRINT NAME OF MEDICAL PROVIDER COMPLETING PSYCHIATRIC MH ASSESSMENTINDICATE M/C CREDENTIAL: MD, NP, etc.DATE:SIGNATURE AND PRINTED NAME OF (if needed) SUPERVISORDATE:INDICATE M/C CREDENTIAL: MD, NP, etc.ADDENDUM ................
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