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
Page 1 of 6
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
Page 2 of 6
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 clients 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:
Page 3 of 6
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:
Page 4 of 6
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
Page 5 of 6
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