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

Ethnicity________________________

Emergency Contact

? Foster Family

? Group Home

? SNF

? B&C

Language Preferred for Services______________________

Relationship

Phone

Address______________________________________________________________________________

Presenting Problem (nature and history)

REV. 3. 2016

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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 :

? Yes, by this Provider

? No (Explain)

Other:

Client Strengths

REV. 3. 2016

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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:

Sexual orientation issues:

? None

? 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

Prior Hospitalization(s)

? No ? Yes

Prior Outpatient Treatment

REV. 3. 2016

? No ? Yes

If yes, describe:

If yes, when, where

? No ? Yes

If yes, when and with whom:

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MENTAL HEALTH PLAN ASSESSMENT FORM

Client Name:

Medical History Health Problems (current) ? No ? Yes

Height:

Weight :

Sleep Disturbance ? No ? Yes

If yes, describe:

Appetite ? Too Little ? Too Much

lbs. Weight Loss:

lbs.

? Cognitive Describe:

Describe:

Adverse response to medications

REV. 3. 2016

(Mandatory if client is a MINOR)

Weight gain:

Disability ? Developmental ? Physical

Allergies ? No ? Yes

If yes, describe:

? No ? Yes

If yes, describe:

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MENTAL HEALTH PLAN ASSESSMENT FORM

Substance Use/ Abuse

Nicotine

Caffeine

Alcohol

Marijuana

Amphetamines

Hallucinogens

Cocaine/Crack

Heroin

Prescription Meds

Other:

No Use

Frequency

Mental Status

Appearance:

Orientation:

Speech:

Thought Process:

Thought Content:

Perceptual Process:

Last Use

?

Clean

Disheveled

Person

Situation

Organized/Clear

Slowed

Organized

Thought Blocking

Poor Concentration

Normal

Other

Normal

Visual hallucinations

Good

None

Good

None

Normal

Elevated

Anxious

Appropriate

Flat

Intact

Recent Memory

Problem

Average

?

?

None

? Cognitive Deficits Present

Concentration Deficits Present

?

?

?

?

?

?

?

?

?

?

?

?

?

Insight:

Judgment:

Mood:

Affect:

Memory:

Estimated Intellectual

Functioning:

Cognitive Deficits:

REV. 3. 2016

Amount

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

Well-groomed

?

Inappropriate clothing

Place

?

Disoriented

?

Coherent

Mumbling

Coherent

?

Flight of Ideas

Obsessive

Delusional

?

Auditory hallucinations

? Other

? Average

?

Dirty

Time

Rapid

Tangential

Grandiose

?

Poor

?

Average

?

?

?

?

?

?

?

?

Hopeless

Irritable

Depressed

?

Labile

Sad

Manic

?

Inappropriate

Blunted

?

Tearful

Immediate Memory Problem

Remote Memory

?

Below Average

?

?

Poor

Above Average

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