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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