Client Name ___________________________ DOB________Sex ...
Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX TransgenderList Name(s) of Person(s) Present: FORMCHECKBOX Person Present FORMCHECKBOX No Show FORMCHECKBOX Person Cancelled FORMCHECKBOX Provider Cancelled Explanation: FORMTEXT ????? FORMCHECKBOX Others Present (please identify name(s) and relationship(s) to person): FORMTEXT ????? Place of Evaluation: FORMCHECKBOX ER FORMCHECKBOX Court FORMCHECKBOX Police Dept. FORMCHECKBOX Outpatient Office FORMCHECKBOX Residential Treatment Setting FORMCHECKBOX ESP FORMCHECKBOX Home FORMCHECKBOX School FORMCHECKBOX Other: FORMTEXT ?????Presenting Concerns in person’s own words; what occurred to cause the person to seek services now: FORMTEXT ?????History of Present Illness: FORMCHECKBOX None Reported FORMTEXT ?????Comprehensive Assessment has been completed? Yes FORMCHECKBOX No FORMCHECKBOX If yes: Date of most recent assessment: FORMTEXT ????? Primary Care Provider Name and CredentialsTel Number FaxAddressDate of Last Exam FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Physical Health HistoryNOTE: I have reviewed the Physical Health Summary in the Comprehensive Assessment of FORMTEXT ????? (date) with the person and: FORMCHECKBOX No additional history to be added, OR FORMCHECKBOX Additional History/Comments: FORMTEXT ?????Family Mental Health / Substance Use History (check all that apply): FORMCHECKBOX None Reported FORMCHECKBOX Schizophrenia FORMCHECKBOX Bipolar FORMCHECKBOX Depression FORMCHECKBOX Anxiety Disorder FORMCHECKBOX ADD FORMCHECKBOX Substance Use FORMCHECKBOX Suicide and / or attempts FORMCHECKBOX Other: FORMTEXT ????? Comments-Specify family member, diagnosis, medication effectiveness: FORMTEXT ?????Substance Use / Addictive Behavior History: NOTE: I have reviewed the Substance Use / Addictive Behavior History in the Comprehensive Assessment of FORMTEXT ????? (date) with the person and: FORMCHECKBOX No additional history to be added, OR FORMCHECKBOX Additional history indicated below:Substance/Alcohol/Tobacco/Gambling/OtherAge of First UseDate of Last UseFrequencyAmountMethod FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Toxicology Screen Completed: FORMCHECKBOX No FORMCHECKBOX Yes – If Yes, Results: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Treatment HistoryNOTE:I have reviewed the Treatment History in the Comprehensive Assessment of FORMTEXT ????? (date) with the person and: FORMCHECKBOX No additional history to be added OR FORMCHECKBOX Additional history indicated below:Type of Service:MH / SUName of Provider/Agency:Dates of Service:Completed? FORMTEXT ????? FORMCHECKBOX MH FORMCHECKBOX SU FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX MH FORMCHECKBOX SU FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX MH FORMCHECKBOX SU FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX MH FORMCHECKBOX SU FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX MH FORMCHECKBOX SU FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoOther Assessment Domains: FORMCHECKBOX I have reviewed the Comprehensive Assessment of FORMTEXT ????? (date) with the person and have added other pertinent information or changes where applicable. FORMCHECKBOX I have not reviewed the comprehensive assessment, but have indicated pertinent information for each of the areas below. Living Situation FORMCHECKBOX No ChangesComments: FORMTEXT ?????Family and Social Supports FORMCHECKBOX No Changes Comments: FORMTEXT ?????Legal Status FORMCHECKBOX No ChangesComments: FORMTEXT ?????Legal Involvement FORMCHECKBOX No Changes FORMCHECKBOX None Reported Comments: FORMTEXT ?????Education FORMCHECKBOX No ChangesComments: FORMTEXT ?????Employment FORMCHECKBOX No ChangesComments: FORMTEXT ?????Military Service FORMCHECKBOX No Changes FORMCHECKBOX None ReportedComments: FORMTEXT ?????Trauma FORMCHECKBOX No Changes FORMCHECKBOX None ReportedComments: FORMTEXT ?????Developmental Issues FORMCHECKBOX N/A FORMCHECKBOX None Reported Comments: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Mental Status Exam – (WNL = Within Normal Limits) (**) – If Checked, Risk Assessment is RequiredAppearance/ Clothing: FORMCHECKBOX WNL FORMCHECKBOX Neat and appropriate FORMCHECKBOX Physically unkempt FORMCHECKBOX Disheveled FORMCHECKBOX Out of the OrdinaryEye Contact: FORMCHECKBOX WNL FORMCHECKBOX Avoidant FORMCHECKBOX Intense FORMCHECKBOX IntermittentBuild: FORMCHECKBOX WNL FORMCHECKBOX Thin FORMCHECKBOX Overweight FORMCHECKBOX Short FORMCHECKBOX TallPosture: FORMCHECKBOX WNL FORMCHECKBOX Slumped FORMCHECKBOX Rigid, Tense FORMCHECKBOX AtypicalBody Movement: FORMCHECKBOX WNL FORMCHECKBOX Accelerated FORMCHECKBOX Slowed FORMCHECKBOX Peculiar FORMCHECKBOX Restless FORMCHECKBOX AgitatedBehavior: FORMCHECKBOX WNL FORMCHECKBOX Cooperative FORMCHECKBOX Uncooperative FORMCHECKBOX Overly Compliant FORMCHECKBOX Withdrawn FORMCHECKBOX Sleepy FORMCHECKBOX Silly FORMCHECKBOX Avoidant/Guarded/ Suspicious FORMCHECKBOX Nervous/ Anxious FORMCHECKBOX Preoccupied FORMCHECKBOX Restless FORMCHECKBOX Demanding FORMCHECKBOX Controlling FORMCHECKBOX Unable to perceive pleasure FORMCHECKBOX Provocative FORMCHECKBOX Hyperactive FORMCHECKBOX Impulsive FORMCHECKBOX Agitated FORMCHECKBOX Angry FORMCHECKBOX Assaultive FORMCHECKBOX Aggressive FORMCHECKBOX Compulsive FORMCHECKBOX RelaxedSpeech: FORMCHECKBOX WNL FORMCHECKBOX Mute FORMCHECKBOX Over-talkative FORMCHECKBOX Slowed FORMCHECKBOX Slurred FORMCHECKBOX Stammering FORMCHECKBOX Rapid FORMCHECKBOX Pressured FORMCHECKBOX Loud FORMCHECKBOX Soft FORMCHECKBOX Clear FORMCHECKBOX RepetitiveEmotional State-Mood (in person’s words): FORMCHECKBOX WNL FORMCHECKBOX Not feeling anything FORMCHECKBOX Irritated FORMCHECKBOX Happy FORMCHECKBOX Angry FORMCHECKBOX Hostile FORMCHECKBOX Depressed, sad FORMCHECKBOX Anxious FORMCHECKBOX Afraid, ApprehensiveEmotional State- Affect FORMCHECKBOX WNL FORMCHECKBOX Constricted FORMCHECKBOX Changeable FORMCHECKBOX Inappropriate FORMCHECKBOX Flat FORMCHECKBOX Full FORMCHECKBOX Blunted, unvaryingFacial Expression FORMCHECKBOX WNL FORMCHECKBOX Anxiety, fear, apprehension FORMCHECKBOX Sadness, depression FORMCHECKBOX Anger, hostility, irritability FORMCHECKBOX Elated FORMCHECKBOX Expressionless FORMCHECKBOX Inappropriate FORMCHECKBOX UnvaryingPerception: FORMCHECKBOX WNL Hallucinations- FORMCHECKBOX Tactile FORMCHECKBOX Auditory FORMCHECKBOX Visual FORMCHECKBOX Olfactory FORMCHECKBOX Command **Thought Content: FORMCHECKBOX WNLDelusions- FORMCHECKBOX None Reported FORMCHECKBOX Grandiose FORMCHECKBOX Persecutory FORMCHECKBOX Somatic FORMCHECKBOX Illogical FORMCHECKBOX Chaotic FORMCHECKBOX ReligiousOther Content- FORMCHECKBOX Preoccupied FORMCHECKBOX Obsessional FORMCHECKBOX Guarded FORMCHECKBOX Phobic FORMCHECKBOX Suspicious FORMCHECKBOX Guilty FORMCHECKBOX Thought broadcasting FORMCHECKBOX Thought insertion FORMCHECKBOX Ideas of referenceThought Process: FORMCHECKBOX WNL FORMCHECKBOX Incoherent FORMCHECKBOX Decreased thought flow FORMCHECKBOX Blocked FORMCHECKBOX Flight of ideas FORMCHECKBOX Loose FORMCHECKBOX Racing FORMCHECKBOX Chaotic FORMCHECKBOX Concrete FORMCHECKBOX TangentialIntellectual Functioning: FORMCHECKBOX WNL FORMCHECKBOX Lessened fund of common knowledge FORMCHECKBOX Impaired concentration FORMCHECKBOX Impaired calculation abilityIntelligence Estimate - FORMCHECKBOX Develop. Disabled FORMCHECKBOX Borderline FORMCHECKBOX Average FORMCHECKBOX Above average FORMCHECKBOX No formal testingOrientation: FORMCHECKBOX WNL Disoriented to: FORMCHECKBOX Time FORMCHECKBOX Place FORMCHECKBOX PersonMemory: FORMCHECKBOX WNL Impaired: FORMCHECKBOX Immediate recall FORMCHECKBOX Recent memory FORMCHECKBOX Remote memory FORMCHECKBOX Short Attention SpanInsight: FORMCHECKBOX WNL FORMCHECKBOX Difficulty acknowledging presence of psychological problems FORMCHECKBOX Mostly blames other for problems FORMCHECKBOX Thinks he/she has no problemsJudgment: FORMCHECKBOX WNL Impaired Ability to Make Reasonable Decisions: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe** Past Attempts to Harm Self or Others: FORMCHECKBOX None Reported FORMCHECKBOX Self** FORMCHECKBOX Others** Self Abuse Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Cutting** FORMCHECKBOX Burning** FORMCHECKBOX Other: FORMTEXT ?????Suicidal Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Passive SI** FORMCHECKBOX Intent** FORMCHECKBOX Plan** FORMCHECKBOX Means** Aggressive Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Intent** FORMCHECKBOX Plan** FORMCHECKBOX Means**Comments: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ????? Record #: FORMTEXT ?????Other symptoms of note or information from other sources (family, referring agency, etc.) FORMCHECKBOX None Reported FORMTEXT ?????Diagnosis: FORMCHECKBOX DSM-IV Codes FORMCHECKBOX DSM 5 Codes FORMCHECKBOX ICD-9 Codes FORMCHECKBOX ICD-10 CodesCheck Primary/Billing Diagnosis CodeNarrative Description FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Medication InformationNOTE: I have reviewed the Medication Information in the Comprehensive Assessment of FORMTEXT ????? (date) with the person and: FORMCHECKBOX There have been no medication changes, OR FORMCHECKBOX Additional medication changes below (include OTC/Herbal Supplements) Medication Current or PastRationale/ ConditionDosage / Route / FrequencyPerson Taking/Took Meds as Prescribed?WA=With Assistance FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WA FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX P FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX WAReported side effects / adverse drug reactions / other comments on current or past medications: FORMTEXT ????? Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Does person served have any medical conditions that require consideration in prescribing (i.e. pregnancy, diabetes, etc.)? FORMCHECKBOX Yes FORMCHECKBOX None reported or known If yes, specify: FORMTEXT ?????Medication Status / Orders FORMCHECKBOX None FORMCHECKBOX As indicated below:Medication StatusRationale/ ConditionDosage / Route / FrequencyAmount/ Refills FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinued FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX New/Adjusted FORMCHECKBOX Refill FORMCHECKBOX Discontinue FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Explained rationale for medication choices, reviewed mixture of medications, discussed possible risks, benefits, effectiveness (if applicable) and alternative treatment with the person (parent/guardian): FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????Person FORMCHECKBOX Understands information FORMCHECKBOX Does not understand FORMCHECKBOX Agrees with Medication FORMCHECKBOX Refuses MedicationGuardian FORMCHECKBOX Understands information FORMCHECKBOX Does not understand FORMCHECKBOX Agrees with Medication FORMCHECKBOX Refuses MedicationLaboratory Tests Ordered: FORMCHECKBOX None Ordered FORMTEXT ?????Follow Up Plan/Referrals (Include all referrals, including commitment orders, those to higher levels of care, labs to be ordered, medical strategies/recommendations, other types of treatment, frequency/interval of next visit and duration): 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Other Psychopharmalogical Considerations to be added to Individualized Action Plan: FORMCHECKBOX None indicated at this time FORMTEXT ?????Person’s /Guardian Response to Plan: FORMCHECKBOX N/A FORMTEXT ?????Physician/APRN/RNCS - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Physician/APRN/RNCS Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Person’s Signature (optional, if appropriate): FORMTEXT ?????Date: FORMTEXT ?????Date of ServiceProvider NumberLoc. CodePrcdr. CodeMod 1Mod2Mod3Mod4Start TimeStop TimeTotal TimeDiagnostic Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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