Person’s Name (First MI Last):



Organization Name: FORMTEXT ?????Program Name: FORMTEXT ????? Date: FORMTEXT ?????Individual’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????DOB: FORMTEXT ?????Date of Referral: FORMTEXT ?????Reason for Referral and Chief Complaint/Presenting ProblemReason for Referral and Chief Complaint/presenting problem-priority and/or emergency issues in individual’s own words: FORMTEXT ?????Family/Guardian description of problem (if relevant): FORMTEXT ?????History of Present Psychiatric Illness (Describe course of presenting stressors/symptoms/concerns): FORMTEXT ?????Past Psychiatric Illness History (Previous episodes of current symptoms and any other past psychiatric concerns): FORMTEXT ?????Substance Use/Addictive Behavior Screen Does individual report problems (historical or current) with any of the following? FORMCHECKBOX Illegal drug FORMCHECKBOX Prescription drug FORMCHECKBOX Non-prescription (OTC) FORMCHECKBOX Alcohol FORMCHECKBOX Gambling FORMCHECKBOX Tobacco FORMCHECKBOX None ReportedMental Health Treatment History FORMCHECKBOX Addiction Treatment Service History FORMCHECKBOX Treatment Services History Within the Past 5 years FORMCHECKBOX None ReportedType of ServicesDates of ServiceReasonName of Provider/Agency:Completed FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesComment further if additional episodes, as indicated: FORMTEXT ?????What was helpful with past treatment? FORMTEXT ?????What was not helpful? FORMTEXT ?????Additional Comments: FORMTEXT ?????Past and Current Social and Developmental Status:Developmental History (Include individual and family history, motor development and functioning, sensory, speech, hearing and language problems, previous diagnosis of developmental disability and any eligibility for Office of Persons with Developmental Disabilities (OPWDD) services): FORMTEXT ????? Sexual HistorySexual History/Concerns (Include sexual orientation and other relevant information; OMH complete Communicable Disease Assessment as indicated): FORMCHECKBOX NA – Based upon the Individual’s age and needs FORMTEXT ????? Vocation/Education/EmploymentHighest Grade Completed FORMCHECKBOX No formal education FORMCHECKBOX Pre-K FORMCHECKBOX Kindergarten FORMCHECKBOX 1st FORMCHECKBOX 2nd FORMCHECKBOX 3rd FORMCHECKBOX 4th FORMCHECKBOX 5th FORMCHECKBOX 6th FORMCHECKBOX 7th FORMCHECKBOX 8th FORMCHECKBOX 9th FORMCHECKBOX 10th FORMCHECKBOX 11th FORMCHECKBOX 12th, no diploma FORMCHECKBOX High School Diploma FORMCHECKBOX General Equivalency Diploma FORMCHECKBOX Vocational Cert w/o Diploma/GED FORMCHECKBOX Vocational Cert w/ Diploma/GED FORMCHECKBOX Some College – No degree FORMCHECKBOX Associates Degree FORMCHECKBOX Bachelors Degree FORMCHECKBOX Graduate DegreeEmployment Status (Select First that applies) FORMCHECKBOX Competitive and integrated employment FORMCHECKBOX Other Employment FORMCHECKBOX Non-paid work position (volunteer) FORMCHECKBOX Unemployed and looking for work FORMCHECKBOX Not in Labor Force: unemployed but not looking for work, retired, homemaker, student, incarcerated or psychiatric inpatient Employment History FORMCHECKBOX NAType of JobHow LongReason for Leaving FORMTEXT ????? FORMTEXT ????? Months / FORMTEXT ????? Years FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Months / FORMTEXT ????? Years FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Months / FORMTEXT ????? Years FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Months / FORMTEXT ????? Years FORMTEXT ?????Approximate Literacy Level (Required for CARF-see Manual) and impact on treatment, if any: FORMTEXT ?????Children and AdolescentsName of School: FORMTEXT ?????Current Grade: FORMTEXT ?????Regular Education Classroom (No Special Services): FORMCHECKBOX No FORMCHECKBOX Yes - If no, check all that apply below.Educational Classification FORMCHECKBOX Autism FORMCHECKBOX Deafness FORMCHECKBOX Deaf-Blindness FORMCHECKBOX Emotional Disturbance FORMCHECKBOX Hearing Impairment FORMCHECKBOX Intellectual disability FORMCHECKBOX Learning disability FORMCHECKBOX Multiple disabilities FORMCHECKBOX Orthopedic Impairment FORMCHECKBOX Other Health Impairment FORMCHECKBOX Speech or language Impairment FORMCHECKBOX Traumatic Brain Injury FORMCHECKBOX Visual ImpairmentAdditional Information, if indicated:Current IEP: FORMCHECKBOX No FORMCHECKBOX Yes Current 504 Plan: FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Home Schooled FORMCHECKBOX Gifted FORMCHECKBOX School/Education History, if indicated: FORMTEXT ?????Comments on Past and Current Academic Functioning (include grades, learning ability, learning style and any other relevant indicators): FORMTEXT ?????Test or Other Evaluation Results (IQ; achievement; developmental; PT/OT; etc.)? FORMCHECKBOX No Test Results Reported FORMTEXT ?????Attendance: FORMCHECKBOX Not a Problem FORMTEXT ?????Previous Grade Retentions: FORMCHECKBOX Denied FORMTEXT ?????Suspensions/Expulsions: FORMCHECKBOX Denied FORMTEXT ?????Additional Barriers to Learning: FORMTEXT ????? Peer Relationship/Social Functioning: FORMTEXT ?????Vocation/Education/Employment Screen/Summary (For Children/Adolescents and Adults)Does the individual want help with or desire further discussion of the following? If yes to any area below, comment on history, strengths, weaknesses and aspirations (required for COA): Vocational FORMCHECKBOX No FORMCHECKBOX Yes - Comment: FORMTEXT ????? Educational FORMCHECKBOX No FORMCHECKBOX Yes - Comment: FORMTEXT ????? Employment FORMCHECKBOX No FORMCHECKBOX Yes - Comment: FORMTEXT ????? Military Service Screen Has the individual ever served in the military? FORMCHECKBOX No FORMCHECKBOX Yes - If yes, Comment: FORMTEXT ????? If yes, is the individual currently experiencing: FORMCHECKBOX Physical health concerns as a result of military experience? FORMCHECKBOX Pain right now or have experienced chronic pain? FORMCHECKBOX Frequent nausea, stomach upset, and/or deliriums? FORMCHECKBOX Concerns of possible infectious agents, toxins, or radiological exposure? FORMCHECKBOX Psychological Issues related to military service (Flashbacks, Nightmares, etc.) FORMCHECKBOX Individual has concerns that seeking help may impact his/her career. Comments: FORMTEXT ?????Further assessment with the Military Service Assessment can be done at any point during care.Is there someone in the family, or a significant other, in the military? FORMCHECKBOX No FORMCHECKBOX Yes - If yes, Comment: FORMTEXT ????? If yes, further assessment with the Military Service Assessment for Significant Others can be done at any point during care.LEGAL INVOLVEMENT HISTORY FORMCHECKBOX None ReportedDoes the individual have a history of, or current, involvement with the legal system (i.e., legal charges, AOT, Specialized Courts-Drug, Mental Health, Family, Arrests, Incarceration, etc.)? FORMCHECKBOX No FORMCHECKBOX YesIs there a family history of, or current involvement with CPS? FORMCHECKBOX No FORMCHECKBOX Yes / APS? FORMCHECKBOX No FORMCHECKBOX Yes If yes to either of the above, complete and attach the Legal Involvement and History Addendum.Legal StatusDoes Individual Served have a Legal Guardian, Rep Payee or Conservatorship? FORMCHECKBOX No FORMCHECKBOX YesIs there a Special Needs Trust other than parent? FORMCHECKBOX No FORMCHECKBOX Yes If yes to either question above, complete and attach the Legal Status AddendumIs there a need for a Legal Guardian, Rep Payee, Conservatorship or Special Needs trust? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain: FORMTEXT ????? Does the individual have any advance directives? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, what type? FORMCHECKBOX DNR FORMCHECKBOX Health Care Proxy FORMCHECKBOX Living Will FORMCHECKBOX Psychiatric Advance DirectiveLiving Situation (Reference Personal Information Form)Household composition and any housing needs: FORMTEXT ?????Family History and RelationshipsComment on family/significant other relationships as applicable (Describe past and current relationships with family/significant others): FORMTEXT ????? Family History of Relevant Health (including Developmental Disabilities), Mental Health, and Addiction concerns: FORMTEXT ?????Custody Issues: FORMCHECKBOX NA OR: Describe custody arrangement/parenting plan as it relates to individual/comments: FORMTEXT ?????Trauma History Does individual report a history, or current experience, of:Select all that are reported: FORMCHECKBOX Physical Abuse/Neglect FORMCHECKBOX Elder Abuse FORMCHECKBOX Community Violence FORMCHECKBOX Verbal/Emotional Abuse FORMCHECKBOX Sexual Abuse/Molestation FORMCHECKBOX Immigration Trauma FORMCHECKBOX Witness to Violence FORMCHECKBOX Domestic Violence FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX None ReportedProvide Relevant Details and Current Clinical Impact: FORMTEXT ?????Social/Leisure Supports/ConcernsFriendships/Social/Pets/Peer Support Relationships: FORMTEXT ????? Meaningful Activities (Community Involvement, Volunteer Activities, Leisure/Recreation, Other Interests): FORMTEXT ?????Community Supports/Self Help Groups (AA, NA, NAMI, Double Trouble, Peer Support, Meals-on-Wheels, etc.): FORMTEXT ?????Religion/Spirituality (Discuss protective and/or risk aspects): FORMTEXT ????? Cultural/Ethnic Information (Discuss protective or risk aspects): FORMTEXT ?????Functional AssessmentComment on daily living skills and ability for self care (including financial needs): FORMTEXT ?????Other functional impairments: FORMTEXT ????? Physical Health History FORMCHECKBOX Refer to Brief Medical Screening Form (includes past and current Medication information) dated: FORMTEXT ????? FORMCHECKBOX Additional Comments, if indicated: FORMTEXT ????? Suicide and Violence RiskSuicide and Self-Harm Screen/AssessmentSources of Information FORMCHECKBOX Columbia-Suicide Severity Rating Scale (C-SSRS) FORMCHECKBOX Clinical Interview FORMCHECKBOX Clinical records FORMCHECKBOX Other approach or evidence based tool (i.e. Chronological Assessment of Suicide Events (CASE) Approach FORMCHECKBOX Collateral sourcesSuicidal ideation (history/current): No Yes – If Yes, provide details: FORMTEXT ?????Suicidal planning (history/current): FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????History of suicidal behaviors? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????History of self-injurious behavior (i.e. cutting, burning)? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, specify and note safety management plan below: FORMTEXT ?????Is there evidence of suicide risk? FORMCHECKBOX No FORMCHECKBOX Yes – If Yes: Does the individual have access to lethal means/weapons? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????Describe discussion with individual/family to secure access to lethal means/weapons. FORMTEXT ?????Identify and discuss impact of significant risk and protective/mitigating factors: FORMTEXT ????? Safety Management Plan: Describe in detail how elements of risk will be managed, including any risk for non-suicidal self-injurious behavior: FORMTEXT ?????Violence ScreenSources of Information FORMCHECKBOX Evidenced-based screening/assessment tool(s) - If Yes, specify: FORMTEXT ????? FORMCHECKBOX Clinical Interview FORMCHECKBOX Clinical records FORMCHECKBOX Collateral sourcesRecent thought/intention or actual plan to hurt others? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????History of threatening/attempting or actually hurting others? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????Current and/or recent thoughts or behaviors that others might interpret as threatening? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, provide details: FORMTEXT ?????Other areas of concern including those from previous sections? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, note below as relevant to risk factors.Is there evidence of violence risk? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes:Does the individual have access to lethal means/weapons? FORMCHECKBOX No FORMCHECKBOX Yes – If Yes, provide details: FORMTEXT ?????Describe discussion with individual/family to secure access to lethal means/weapons. FORMTEXT ?????Identify and discuss impact of significant risk and protective/mitigating factors: FORMTEXT ????? Safety Management Plan: Describe in detail how elements of risk will be managed and/or how continued assessment will be conducted: FORMTEXT ?????Life Goals, Strengths, Abilities, and BarriersLife Goals: FORMTEXT ?????Strengths (skills, talents, interests, protective factors): FORMTEXT ?????Barriers (environmental and personal): FORMTEXT ?????Past and Present Successes in Achieving Desired Goals: FORMTEXT ?????Service Preferences: describe individual/family/guardian/significant other perception of needs and preferences for health care and behavioral health services, including family participation in care and environmental supports (self-help, advocacy and empowerment activities): FORMTEXT ????? Summary and Functional Eligibility Summary: What are the need areas and determination of the recipient's functional eligibility for services? (discuss the factors that led to the needs, and the skills and resources needed to address them. Comment on desire and motivation to learn, and ability/capacity to respond to services. Base summary on full Assessment which includes Referral Information, Personal Information Form and additional assessments/addendums completed (i.e. Brief Medical Screening; Communicable Disease; Substance Abuse; Legal, etc.). FORMTEXT ????? Diagnosis: FORMCHECKBOX DSM Codes FORMCHECKBOX ICD Codes From Referral Information Record/Date: FORMTEXT ?????Check PrimaryAxisCodeNarrative Description FORMCHECKBOX Axis I FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Axis II FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Axis III FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Axis IV FORMCHECKBOX No FORMCHECKBOX YesProblems with primary support group:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesProblems related to the social environment:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesEducational problems:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesOccupational problems:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesHousing problems:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesEconomic problems:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesProblems with access to health care services:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesProblems with interaction with the legal system/crime:If Yes, describe: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX YesOther psychosocial and environmental problems:If Yes, describe: FORMTEXT ?????Axis VCurrent GAF: FORMTEXT ?????Highest GAF in Past Year (if known): FORMTEXT ?????Further Evaluations Needed: FORMCHECKBOX None Indicated FORMCHECKBOX Psychiatric FORMCHECKBOX Psychological FORMCHECKBOX Neurological FORMCHECKBOX Medical FORMCHECKBOX Educational FORMCHECKBOX Employment FORMCHECKBOX Visual FORMCHECKBOX Auditory FORMCHECKBOX Nutritional FORMCHECKBOX Other: FORMTEXT ?????Prioritized Assessed Needs:A-Active, IFD-Individual or Family/Guardian Declined, D-Deferred, N/A-Not Applicable, R-Referred OutAIFD*D*NA*R*1. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX *Individual Declined/Deferred/Referred Out-Rationale(s) (Explain why the Individual Declined to work on Need Area; List rationale(s) for why Need Area(s) is/are Deferred/Referred Out/NA; Offer time frame for deferment below). FORMCHECKBOX None 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????6. FORMTEXT ?????7. FORMTEXT ?????8. FORMTEXT ?????Individual Served/Guardian/Family Response to Recommendations (if family did not participate explain why): FORMTEXT ?????Individual Served Signature (Optional):Date: FORMTEXT ?????Guardian Signature (Optional):Date: FORMTEXT ?????Completed By - Print Name/Credentials: FORMTEXT ?????Staff Signature:Date: FORMTEXT ?????Team Leader/Clinical Supervisor - Print Name/Credentials (if needed): FORMTEXT ?????Team Leader/Clinical Supervisor Signature (if needed):Date: FORMTEXT ?????For programs using this as a billable note, fill out Billing Strip below.Date of ServiceStaff IdentifierLoc. CodeService CodeMod 1Mod 2Mod 3Mod 4Start TimeStop TimeDuration in Minutes FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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