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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