New River Health Association, Inc
Anywhere School Health Center
Address
Phone
Behavioral Health Services - Child/Adolescent Assessment
Student’s Name: D.O.B: Grade: ____
Referred by: Chart #: _____________
Chief Complaint (Reason for Referral/Presenting Problem):
( Academic ( Behavior ( Peer Relationships ( Family Relationships
( Substance Abuse ( Physical/Sexual Abuse ( Other Stressors
Living Situation:
( Both biological parents ( One parent ( Step parent in home
( Grandparent(s) ( Foster parent ( Juvenile home
( Other:
Other persons living in home:
Who has legal custody:
School Academics/Behavior:
( General Studies ( Vocational ( Special Education/Remedial Class
( Alternative Program ( Retained in Past ( Suspensions/Detentions
( Problems with teachers ( Problems with peers
( Other/Comments:
Favorite classes and why:
Least favorite classes and why:
Academic Performance: ( Outstanding ( Satisfactory ( Failing
Previous Academic Performance: ( Outstanding ( Satisfactory ( Failing
Substance Use: (Tobacco (Caffeine (Alcohol (Marijuana (Cocaine
(Acid (RX pills (Other:
Age of first use: Frequency:
Patient thinks substance abuse is a problem for him/her: Yes No ___
Alcohol/Substances have been a problem for other family members: Yes No ___
Medical History/Medications:
Mental Health Services/Medications:
Other services patient is involved in: ( DHHR ( Other Counseling Services
Social/Community/Interests & Hobbies:
( Has many friends ( Has best friend ( Has friends over to home
( Spends time at friend’s home ( Attends community functions
Leisure Interests:
Sexual Behaviors/Issues:
Sleep Patterns:
Has difficulty sleeping Yes No If yes, patient displays:
( Nightmares ( Frequent waking ( Early morning wake-up
( Excessive time falling asleep ( Insomnia ( Night terrors
Weight or Food Issues: ( Overweight ( Underweight ( Satisfied with weight/body image
Patient Name: Chart #:
Strengths and Resources:
Assessment/Preliminary Diagnosis:
Treatment Type: ( Individual ( Family ( Group Frequency:
Solution Focused Therapy Homework given Support
Insight Family Education
Behavioral Relationship Resource Linkage
Cognitive Problem Solving Advocacy
Additional Comments:
Plan/Homework:
MENTAL STATUS/BEHAVIORAL ASSESSMENT
Conversation:
( Relevant ( Free Flowing ( Irrelevant ( Guarded ( Rambling
( Other
Affect:
( Flat ( Blunted ( Appropriate ( Labile ( Broad ( Restricted
( Inappropriate
Mood:
( Normal ( Euphoric ( Euthymic ( Elated (Depressed ( Anxious
( Irritable ( Expansive ( Dysphoric ( Other:
Mood and Affect:
( Congruent ( Incongruent
Speech:
( Soft ( Loud ( Pressured ( Audible ( Inaudible
( Rapid ( Slurred ( Slow ( Stuttering ( Other:
Psychotic Symptoms:
( None ( Auditory Hallucinations ( Visual Hallucinations
( Tactile Hallucinations ( Olfactory Hallucinations ( Other:
Thinking:
( Appropriate ( Loose Associations ( Flight of Ideas ( Slow ( Delusional
( Ideas of Reference ( Preoccupied ( Homicidal ( Suicidal ( Disoriented
( Poor Concentration
Behavior and Manner:
( Cooperative ( Established Rapport ( Polite and Courteous ( Sociable
( Eye Contact ( Uncooperative ( LOA ( Rude ( Evasive
( Posture ( Fidgety ( Lethargic ( Easily Distracted
( Short Attention Span ( Intrusive ( Talkative ( Oppositional Behavior
( Aggressive Behavior ( Fine Motor Coordination ( Gross Motor Coordination
Appearance:
( Appropriate ( Clean ( Neat ( Casual ( Formal ( Untidy
( Glasses ( Visual Problems ( Hearing Problems ( Motor Problems
( Appearance in relation to age: ( Clothing style:
( Reviewed limits of confidentiality ( Parental Consent in chart
Scores from Objective Survey (HAD, CDI, Connors, etc.)
Children’s Developmental Questionnaire: ( Yes ( No ( N/A
Issues from GAPS Screening:
Counselor: Date: __________
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