Assessment Initial



|Provider:       | |Coordinator:       |

| |Out of Area COUNTY______________________ | |

| |Mental Health Plan | |

|Program:       | |Phone:       |

|Cost Center-Reporting Unit:       |CHILD & YOUTH COMPREHENSIVE |Fax:       |

| |ASSESSMENT | |

|Program Admit Date:       | |Date Completed:     |Minutes:       |

|Requested AUTHORIZATION |START DATE:       |END DATE:       | |

|CLIENT NAME: |      |Sex: |DOB:       |Age Today: |Client MRN: |

| | |M F | | | |

| | | | | |SSN: |

|CAREGIVER:       |Phone: |Relationship: |

| |      |      |

|Address:       |City: |Zip: |

| |      |      |

|LEGAL GUARDIAN:       |Phone: |Relationship: |

| |      |      |

|Address:       |City: |Zip: |

| |      |      |

|REFERRAL SOURCE: | CWS/CPS School Physician Parent / Caregiver |Phone: |Contact: |

| |Therapist Probation Self Other |      |      |

|LEGAL STATUS AND SPECIAL POPULATIONS: | |

| Voluntary Dep. of Court (300 W&I) Alta Regional Ctr. 26.5 / AB3632 |Comments:       |

|Foster Child On Probation (600 W&I) Aid to Adoptive Parent(s) Other | |

|Language spoken most frequently in the home (check only one): |

| 1 - Cambodian | 4 - Hmong | 7 - Lao | 10 - Romanian | 13 - Spanish | 16 - Tongan |

| 2 - Cantonese | 5 - Japanese | 8 - Mandarin | 11 - Russian | 14 - Tagalog | 17 - Vietnamese |

| 3 - English | 6 - Korean | 9 - Mien | 12 - Samoan | 15 - Thai | 18 -       |

|FUNCTIONAL IMPAIRMENT PRESENTING PROBLEMS / TARGETED SYMPTOMS / REASONS FOR SERVICE: |

|Functioning (Please assess how current symptoms have effected the level of impairment in the following categories and indicate anticipated impairment at discharge) |

| |

|Impairment Level (Circle One for Each identified Category) |

|Anticipated Impairment at Discharge |

| |

|Categories |

|None |

|Mild |

|Moderate |

|Marked |

|Extreme |

|(E.g., “2”) |

| |

|Problems w/primary Support |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|School Performance due to Mental Health Issues |

|(Note Level and check if other categories are applicable) |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

| |

|□ Truant □ School suspension □ AB3632 |

| |

| |

|Friendship/Peer Relationships |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Self care/daily activities |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Depressive Symptoms |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Mania/Agitation/Lability Symptoms |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Physical Health Status/Somatic Disturbances |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Oppositional to following directions |

|□ school |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

| |

|□ home |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Appetite disorder/Sleeping Disturbances (circle) |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Anxiety/Phobia/Panic Attacks |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Interaction with legal system due to Mental Health Issues |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Ability to Concentrate/Attention/Cognition/Memory/Thought |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Ability to Control His/Her Temper/Affect Regulation/Impulsivity |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Destructive/Assaultive |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Problems related to socialization/Communication |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Perceptual Disturbances (Hallucination, Delusions, Paranoia…) |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|Other: |

|1 |

|2 |

|3 |

|4 |

|5 |

| |

| |

|CLIENT NAME:       |CLIENT MRN#: |

|PROBLEM AREA ASSESSMENT / FUNCTIONAL IMPAIRMENT: |

|Rate the following problem areas. Problems marked “Severe” must be followed up on immediately. Provide details in the PRESENTING PROBLEMS section and an action |

|plan in the SUMMARY section on page 6. |

|PROBLEM AREAS: |History (past)|Severity of Problem in last 2 months |Potential Risk (immediate future, up to 60 |

| |Yes No |(current) |days) |

| | |None Insignificant Mild |None Insignificant Mild |

| | |Moderate Severe |Moderate Severe |

|CLIENT NAME:       |CLIENT ID#: |

|CLIENT’S MENTAL HEALTH HISTORY:       |INCLUDE: |

| |Earliest symptoms |

| |Age at onset |

| |Family understanding of the problem |

| |Other supports/stressors at the time of |

| |onset |

| |Response to treatment |

| |Other potential contributing factors |

| Yes No Previous outpatient mental health services? When/where? Transfer       |

| Yes No Previous crisis contact? Number of crisis unit visits without hospitalization in past 6 months: 0 1 2 or more Most recent date:       |

| Yes No Previous psychiatric hospitalization? Number of psychiatric hospitalizations in past 6 months: 0 1 2 or more Most recent date:       |

| Number of days hospitalized in the past 6 months:       |

| Yes No Use of traditional or alternative healing practices (describe, with results):       |

|      |

|SUBSTANCE USE/ABUSE (Please answer the following questions about all current drug and alcohol use.) List applicable drug(s) for items marked “True”: |

|1. | True False Drinking or drug use sometimes causes me to miss school, work, or important appointments.       |

|2. | True False I sometimes drink or use drugs when it is dangerous to do so.       |

|3. | True False I sometimes have problems with the police or school authorities due to my drinking or drug use.       |

|4. | True False I sometimes drink or use drugs even though they cause problems in my life.       |

|5. | True False I need more to get drunk or high now than I used to. (Tolerance)       |

|6. | True False Trying to quit makes me sick; I get withdrawal symptoms. (Withdrawal)       |

|7. | True False I sometimes end up drinking or using more than I meant to.       |

|8. | True False I have tried to quit before, but failed. (Give approximate dates for each applicable drug.)       |

|9. | True False I spend more and more time getting and using drugs/alcohol.       |

|10. | True False I sometimes choose drugs or alcohol over friends and family.       |

|11. | True False I keep using even though the drug/alcohol makes me sick or messes with my mind.       |

|TYPE OF SUBSTANCE |PRENATAL |AGE AT FIRST|CURRENT SUBSTANCE USE | |

| |EXPOSURE |USE | | |

|Check if ever used: |Unknown |    |None/ Denies |

| | | | |

|ALCOHOL | | | |

| If yes, type of alcohol and drug services: | Residential | Outpatient | Community/Support |

| | | |Group |

|LIST CLIENT’S SUBSTANCE ABUSE GOAL(S) AND ANY ADDITIONAL COMMENTS (including perceived benefits and abstinence/recovery issues): |

|      |

|CLIENT NAME:       |CLIENT MRN: |

|Current Psychiatric Medications (check all categories that apply and list names & doses below): |

| 0 – None | 1 – Anti-depressants: | 2 – Mood Stabilizers: | 3 – Anti-psychotics: | 4 – Anxiolytics: | 5 – Stimulants: |

|9 – Other (list): |(Zoloft, Paxil, |(Lithium, Depakote, Tegretol…) |(Zyprexa, Risperdal…) |(Xanax) |(Ritalin, Adderal) |

| |Wellbutrin…) | | | | |

| 10 – History only (no current medications; list previous): |

|Drug Names/Dosages/Month & Year Prescribed/Physicians: |

|      |

|Compliance Issues? | Unknown | No | Yes |Explain: |

|Client’s Medical History: | Not Available |Comments: |

| |

|Current Primary Medical Care Provider: |

| Last Physical Exam: | Within Past 12 months | More than 12 months | Unknown | No | |

| Last Dental Exam: | Within Past 12 months | More than 12 months | Unknown | No |Explain: |

| Are there any health concerns (medical illness, medical symptoms)? | Unknown | No | Yes |Explain: |

| Non-Medication Allergies (Food, Pollen, Bee sting, etc)? | Unknown | No | Yes |Explain: |

| Medication Allergies?(list type) | Unknown | No | Yes |Explain: |

|Has the child had any of the following problems/experiences? (Check all that apply) |

| Asthma | Heart Problems | Surgery of any kind? |Explain: |

| Broken Bones | High or Low Blood Pressure | Thyroid Problem | | | | |

| Convulsion or Seizure | Immune System Problems | Tuberculosis (TB) | | | | |

| Diabetes | Liver Problems or Hepatitis | Urinary Tract or Kidney Problem | | | |

| Exposure to Toxic Lead Levels | Motor or Movement Problems | Weight Gain or Loss |Explain: |

| Head Injury | Pregnancy | Speech of Language Problems |Explain: | | |

| Hearing Problems | Serious Rash or Other Skin Problem | Other: | | | | | |

| Vision Problems | Sexually Transmitted Disease (STD) | | | | | | |

| | | | | | | | |

|CHILD, YOUTH, AND FAMILY STRENGTHS/ASSETS: |Consider Assets, Strengths, Challenges & Needs in the |

| |following areas: |

|      |Motivation/Insight |Social/Interpersonal |

| |Family |Psychological |

| |Special Talents |Emotional |

|CHALLENGES AND NEEDS: |Abilities/Interests |Community Support |

|      |Educational |Economic |

| |Vocational |Ability to Access Care |

| |Cultural/Spiritual |Needs outside system |

| |Safety |Medical/Health |

|CLIENT NAME:       |CLIENT MRN: |

|MENTAL STATUS EXAMINATION (choose at least one descriptor) Note Cultural & Age explanation for descriptors when applicable: |

|APPEARANCE | Normal for culture and age disheveled meticulous poor hygiene |Comments:       |

| |eccentric seductive inappropriate older/younger than stated age | |

|ATTITUDE | engaging cooperative uncooperative angry/hostile guarded |Comments:       |

| |provocative sarcastic irritable apathetic shy/timid | |

| |silly/naive manipulative dependent demanding impulsive | |

| |callous evasive sensitive tearful overly dramatic | |

|BEHAVIOR |Eating level: Above Normal Normal Below Normal |Comments:       |

| |Energy level: Above Normal Normal Below Normal | |

| |Sleeping level: Above Normal Normal Below Normal | |

| |nightmares | |

|MOTOR ACTIVITY | calm/normal lethargic panicky restless, pacing repetitive |Comments:       |

| |tics tremors posturing hyper-active unusual gait | |

| |Eye contact: direct/good staring evasive poor | |

|SENSORIUM | alert clouded confused disoriented stuporous |Comments:       |

| |Orientation: person place day/date/year situation | |

| |INTELLIGENCE (by impression): average above average below average | |

|MOOD | euthymic (normal range) depressed (extremely sad, despondent) |Comments:       |

| |sad elevated (more cheerful than normal) | |

| |irritable euphoric (exaggerated feeling of well being) | |

| |anxious | |

|AFFECT | broad (within normal limits) restricted blunted (severely reduced intensity) |Comments:       |

| |flat (lack of affective expression) labile (rapid shifts in mood, unstable) | |

| |mood incongruent | |

|PERCEPTION |Within Normal Limits |Comments:       |

| |Hallucinations: visual auditory other | |

| |Other Perceptual Distortions: derealization depersonalization dissociation | |

| |distortion of body image | |

|THOUGHT FORM/PROCESS| logical linear tangential circumstantial loose |Comments:       |

| |scattered blocked fragmented flight of ideas perseverative | |

| |racing thoughts | |

|THOUGHT CONTENT | Within Normal Limits |Comments:       |

| |Delusions: grandiose paranoid somatic jealous | |

| |erotomanic thought broadcasting other | |

| |Other Thought Distortions: obsessions compulsions hypervigilance | |

| |suspiciousness phobias magical thinking / ideas of reference | |

| |religiosity guilt sexual preoccupation | |

|SPEECH | Within Normal Limits incoherent halting mute |Comments:       |

| |loud soft rapid pressured slurred | |

| |stammer monotone monosyllabic rambling echolalia | |

| |word salad clanging impoverished excessive profanity | |

|MEMORY |Remote (history, life events) Adequate Fair Poor |Comments:       |

| |Recent (past 24 hours) Adequate Fair Poor | |

| |Immediate (past 5-10 minutes) Adequate Fair Poor | |

|CONCENTRATION | attentive distracted unable to concentrate |Comments:       |

|JUDGMENT | Age-appropriate Fair Poor |Comments:       |

|INSIGHT | Age-appropriate self-awareness (Understanding of own challenges and motivation) |Comments:       |

| |Blames others or external factors for problems Denies illness / disability | |

|ABSTRACT THINKING | Age-appropriate Significant limitations Very concrete |Comments:       |

|Summary Comments:       |

|CLIENT NAME:       |MRN:       |

|LPHA DIAGNOSIS SOURCE:      , Lic/Reg: |DATE: |

|ICD 9 CODE: (Principle)       |

|Axis I |(Primary)       |

|Axis I |(Secondary)       |

|Axis II |(Primary)       |Axis II |(Secondary)       |

|Axis III|      |

|Axis IV |1 Primary Support |Comments:       |

| |2 Social Environment |Comments:       |

| |3 Education |Comments:       |

| |4 Occupational |Comments:       |

| | 5 Housing |Comments:       |

| |6 Economic |Comments:       |

| |7 Access to Healthcare |Comments:       |

| |8 Legal System |Comments:       |

| |9 Other |Comments:       |

| |0 (None Evident) |Comments:       |

|Axis V |Current GAF:       Past Year (Optional) GAF: |Comments:       |

| |      | |

|CLINICAL FORMULATION |

|Use specific behavioral descriptors to address additional clinical information that impacts treatment. (e.g., progression of symptoms, test results/lab values, |

|pertinent history, concomitant issues, factors impeding progress, effectiveness of current strategies.) |

|__________________________________________________________________________________________________________________________ |

|__________________________________________________________________________________________________________________________ |

|__________________________________________________________________________________________________________________________ |

|__________________________________________________________________________________________________________________________ |

|__________________________________________________________________________________________________________________________ |

|SUMMARY / ADDITIONAL COMMENTS /CONTINUATION FROM OTHER SECTIONS (Include immediate plans for risk indicators and safety plan): |

| |

| |For additional space, check here and |

| |attach Additional Page(s) |

|CLIENT NAME: |MRN: |

|TENTATIVE DISCHARGE PLAN:       |

|Coordination of Care (mark all that apply, list by number below): |

| 1 - Additional Outpatient MH Provider |

|2 - Day Treatment/Day Rehab |

|3 - Wraparound |

|4 – TBS |

|5 - Transition Age Youth Services |

|6 - 0-5 Program |

|7 – Child Case Mgmt. |

|8 - Alta Regional Center |

|9 - Residential Services |

|10 - Psychological Testing |

|11 - Psychiatric Services |

|12 - Drug & Alcohol Services |

|13 - Foster Family |

|14 - Child Welfare/CPS |

|15 - Probation Officer |

|16 - Social Worker |

|17 - Physician/Pediatrician |

|18 - Other healthcare provider |

|19 - Non-custodial caregiver |

|20 - Other |

| |

|# |Name |Agency/Contact Information |Phone Number |

|   |      |      |      |

|   |      |      |      |

|   |      |      |      |

|   |      |      |      |

| |

|Teacher’s Name |School |Phone |Active IEP? | YES |

| | | | | NO |

|      |      |      | |

|      |      |      | |

|Include meeting date(s) and specific roles and outcomes from Coordination Meeting (If Applicable): | Not Applicable |

|      |

|Notice of Privacy Practices Offered to Client/Caregiver? Yes No | No |

|SIGNATURES:. |

|Provider:       |Agency/Title:       |Date:       |

|LPHA Co-signature |Agency/Title:       |Date:       |

|(if required): | | |

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(OUT佃䕍⥓഍഍഍഍COMES)

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