Adult Diagnostic Assessment



Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX TransgenderPresenting Concerns (In Person’s /Family’s Own Words)Referral Source: FORMTEXT ?????Reason for Referral: FORMTEXT ?????What Occurred to Cause the Person to Seek Services Now (Note Precipitating Event, Symptoms, Behavioral and Functioning Needs): FORMTEXT ?????Living SituationWhat is the person’s current living situation? (check one) FORMCHECKBOX Rent FORMCHECKBOX Own FORMCHECKBOX Friend’s Home FORMCHECKBOX Relative’s/Guardian’s Home FORMCHECKBOX Foster Care Home FORMCHECKBOX Respite Care FORMCHECKBOX Jail/Prison FORMCHECKBOX Homeless living with friend FORMCHECKBOX Homeless in shelter/No residence FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Residential Care/Treatment Facility: FORMCHECKBOX Hospital FORMCHECKBOX Temporary Housing FORMCHECKBOX Residential Program FORMCHECKBOX Nursing/Rest Home FORMCHECKBOX Supportive HousingAt Risk of Losing Current Housing FORMCHECKBOX Yes FORMCHECKBOX No Satisfied with Current Living Situation FORMCHECKBOX Yes FORMCHECKBOX No Comments (Include environmental surroundings and neighborhood description): FORMTEXT ?????Family HistoryFamily History and Relationship, Parental/ Familial Caretaker Obligations: FORMTEXT ?????Pertinent Family Medical, MH and SU History: FORMTEXT ?????Developmental History and Status: FORMTEXT ?????Social Support Friendship/Social/Peer Support Relationships, Pets, Community Supports/Self Help Groups (AA, NA, SMART, NAMI, Peer Support, etc.): FORMTEXT ?????Religion/Spirituality and Cultural/Ethnic Information: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Legal Status and Legal Involvement HistoryDoes Person Served have a Legal Guardian, Rep Payee or Conservatorship? FORMCHECKBOX No FORMCHECKBOX Yes; If yes, complete and attach the Legal Status AddendumIs there a need for a Legal Guardian, Rep Payee or Conservatorship? FORMCHECKBOX No FORMCHECKBOX Yes / Explain: FORMTEXT ?????Does the person have a history of, or current involvement with the legal system (i.e., legal charges)? FORMCHECKBOX No FORMCHECKBOX Yes; If yes, complete and attach the Legal Involvement and History AddendumEducation Highest Level of Education Achieved: FORMCHECKBOX GED FORMCHECKBOX HS Grad FORMCHECKBOX College FORMCHECKBOX Vocational Training FORMCHECKBOX Graduate Degree Highest Grade Completed: FORMTEXT ?????Person’s Preferred Learning Style(s): FORMCHECKBOX Visual FORMCHECKBOX Auditory FORMCHECKBOX Verbal FORMCHECKBOX Written FORMCHECKBOX Learn by doingCurrently Enrolled in Educational Program?: FORMCHECKBOX No FORMCHECKBOX Yes; If yes, complete and attach Education AddendumIs person interested in further education or assistance in education?: FORMCHECKBOX No FORMCHECKBOX Yes: If yes, complete and attach Education AddendumEmployment and Meaningful Activities Employment Status/Interests: FORMTEXT ????? FORMCHECKBOX Never Worked Currently Employed? FORMCHECKBOX No FORMCHECKBOX Yes; If yes, length of employment: FORMTEXT ????? (If not currently employed) – Person served wants to work? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Uncertain / Comments: FORMTEXT ????? Does the person want help to find employment or vocational training? FORMCHECKBOX No FORMCHECKBOX Yes / Comments: FORMTEXT ????? If yes, complete Employment AddendumMeaningful Activities (Community Involvement, Volunteer Activities, Leisure/Recreation, Other Interests): FORMTEXT ?????Income/Financial SupportHow does the person describe her/his current financial situation? FORMCHECKBOX Comfortable/ living within means FORMCHECKBOX Occasional struggle with finances FORMCHECKBOX Often struggles with finances FORMCHECKBOX Financial struggles are a major source of stress Comments: FORMTEXT ????? Do you receive any sources of financial assistance? FORMCHECKBOX SSI FORMCHECKBOX SSDI FORMCHECKBOX Food Stamps FORMCHECKBOX Contributions from family or friends FORMCHECKBOX Disability FORMCHECKBOX Child Support FORMCHECKBOX Veterans Benefits FORMCHECKBOX TAFDC FORMCHECKBOX EAEDC FORMCHECKBOX Other: FORMTEXT ?????If yes, Type and Amount: FORMTEXT ????? Military Service FORMCHECKBOX None Reported - If None Reported, skip to the Substance Use / Addictive Behavior History SectionMilitary Status: FORMCHECKBOX Active FORMCHECKBOX VeteranDate of Discharge: FORMTEXT ????? Type of Discharge: FORMCHECKBOX 1. Honorable FORMCHECKBOX 2. General (under Honorable Conditions FORMCHECKBOX 3. Other than Honorable FORMCHECKBOX 4. Bad Conduct FORMCHECKBOX 5. DishonorableReason: FORMTEXT ?????Is a complete Military Service assessment needed? FORMCHECKBOX No FORMCHECKBOX Yes; If yes, complete and attach Military Service AddendumAddictive Behavior and Substance Abuse HistoryDoes person report a history of, or current, substance use or other addictive behavior concerns (i.e., alcohol, tobacco, gambling, food)? FORMCHECKBOX No FORMCHECKBOX Yes;. If yes, complete and attach Addictive Behavior History/SA Addendum. Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Mental Health and Addiction Treatment History Type of ServiceDates of ServiceReasonName of Provider/ Agency:Inpatient/ OutpatientCompleted FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ????? FORMTEXT ?????/ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX In FORMCHECKBOX Out FORMCHECKBOX No FORMCHECKBOX YesEfficacy of past and current treatment: FORMTEXT ?????Psychiatric History (including past diagnoses): FORMTEXT ?????Source(s) of Information: FORMCHECKBOX Person Served FORMCHECKBOX Significant other/Family member(s) FORMCHECKBOX Service Provider(s) FORMCHECKBOX Case Manager FORMCHECKBOX Written records FORMCHECKBOX Other: FORMTEXT ?????Physical HealthPCP, Medical Specialist and DentistName, Credentials, SpecialtyTelephone NumberFax NumberAddressDate of Last Exam FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Physical Health Summary OR FORMCHECKBOX Refer to Attached Physical Health AssessmentBureau of Substance Abuse Services (BSAS) Programs must complete the MSDP Infectious Disease Risk Addendum and the BSAS TB AssessmentAllergies: FORMCHECKBOX No Known Allergies FORMCHECKBOX Yes, list below:Food: FORMTEXT ????? Medication Allergies and Medication Sensitivities (including OTC, herbal): FORMTEXT ????? Environmental: FORMTEXT ????? Physical Health Summary: (Include health history, chronic conditions, significant dental history, and current physical complaints that may interfere with the person’s served functioning.) FORMTEXT ?????Does the person use complimentary health approaches (e.g. natural products, mind-body practices, yoga)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please describe: FORMTEXT ?????Does the person wish to consider using complimentary health approaches and want help finding a provider? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf yes, please describe: FORMTEXT ?????Sexual History/Concerns: FORMTEXT ?????Pain Screening: Does the person experience pain currently? FORMCHECKBOX Yes FORMCHECKBOX No Has the person experienced pain in past few months? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe the type, frequency, duration, intensity, identified cause, any limitations to functioning and what helps relieve the pain: FORMTEXT ?????Nutritional Screening: (check all that are reported) FORMCHECKBOX Special diet? (e.g. diabetic, celiac) Follows special diet? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Medications affecting nutritional status FORMCHECKBOX Weight gain/loss of 10 pounds or more without specific diet FORMCHECKBOX Change in appetite FORMCHECKBOX Binging FORMCHECKBOX Purging FORMCHECKBOX Use of laxatives FORMCHECKBOX Intense focus on weight, body size, calorie intake, exerciseBeliefs, perceptions, attitude, behaviors regarding food: FORMTEXT ?????Physical Health Summary and Recommendations:If person has not had physical exam in past year, or if person has reported pain without a determined cause, or if person has reported eating disordered behaviors that are not being medically followed: FORMCHECKBOX Referral for physical exam FORMCHECKBOX Referral for Nutritional Assessment FORMCHECKBOX Person declined exam (reason): FORMTEXT ????? FORMCHECKBOX PCP contactedMedication SummaryMedication information and history of adverse reactions: (Include what medications work well and have worked well previously, any adverse side effects, why person doesn’t take meds as prescribed and/or which one(s) the person would like to avoid taking in the future): FORMTEXT ????? Is the person served currently taking any medication FORMCHECKBOX No FORMCHECKBOX Yes; If yes, complete and attach the Medication AddendumAdvanced DirectiveDoes the person have advanced directive established FORMCHECKBOX No FORMCHECKBOX YesIf yes, what type? FORMCHECKBOX Living Will FORMCHECKBOX Power of Attorney FORMCHECKBOX Health Care Proxy FORMCHECKBOX Other: FORMTEXT ?????If no, does the person wish to develop them at this time? FORMCHECKBOX No FORMCHECKBOX Yes / If yes, follow agency’s procedure for completionTrauma History Does person report a history of trauma? FORMCHECKBOX No FORMCHECKBOX YesDoes person report history/current family/significant other, household, and/or environmental violence, abuse or neglect or exploitation? FORMCHECKBOX No FORMCHECKBOX YesIf the answer to either of the above questions is yes, complete and attach the Trauma History Addendum.Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Mental Status Exam – (WNL = Within Normal Limits) (**) – If Checked, Risk Assessment is RequiredAppearance/ Clothing: FORMCHECKBOX WNL FORMCHECKBOX Neat and appropriate FORMCHECKBOX Physically unkempt FORMCHECKBOX Disheveled FORMCHECKBOX Out of the OrdinaryEye Contact: FORMCHECKBOX WNL FORMCHECKBOX Avoidant FORMCHECKBOX Intense FORMCHECKBOX IntermittentBuild: FORMCHECKBOX WNL FORMCHECKBOX Thin FORMCHECKBOX Overweight FORMCHECKBOX Short FORMCHECKBOX TallPosture: FORMCHECKBOX WNL FORMCHECKBOX Slumped FORMCHECKBOX Rigid, Tense FORMCHECKBOX AtypicalBody Movement: FORMCHECKBOX WNL FORMCHECKBOX Accelerated FORMCHECKBOX Slowed FORMCHECKBOX Peculiar FORMCHECKBOX Restless FORMCHECKBOX AgitatedBehavior: FORMCHECKBOX WNL FORMCHECKBOX Cooperative FORMCHECKBOX Uncooperative FORMCHECKBOX Overly Compliant FORMCHECKBOX Withdrawn FORMCHECKBOX Sleepy FORMCHECKBOX Silly FORMCHECKBOX Avoidant/Guarded/ Suspicious FORMCHECKBOX Nervous/ Anxious FORMCHECKBOX Preoccupied FORMCHECKBOX Restless FORMCHECKBOX Demanding FORMCHECKBOX Controlling FORMCHECKBOX Unable to perceive pleasure FORMCHECKBOX Provocative FORMCHECKBOX Hyperactive FORMCHECKBOX Impulsive FORMCHECKBOX Agitated FORMCHECKBOX Angry FORMCHECKBOX Assaultive FORMCHECKBOX Aggressive FORMCHECKBOX Compulsive FORMCHECKBOX RelaxedSpeech: FORMCHECKBOX WNL FORMCHECKBOX Mute FORMCHECKBOX Over-talkative FORMCHECKBOX Slowed FORMCHECKBOX Slurred FORMCHECKBOX Stammering FORMCHECKBOX Rapid FORMCHECKBOX Pressured FORMCHECKBOX Loud FORMCHECKBOX Soft FORMCHECKBOX Clear FORMCHECKBOX RepetitiveEmotional State-Mood (in person’s words): FORMCHECKBOX WNL FORMCHECKBOX Not feeling anything FORMCHECKBOX Irritated FORMCHECKBOX Happy FORMCHECKBOX Angry FORMCHECKBOX Hostile FORMCHECKBOX Depressed, sad FORMCHECKBOX Anxious FORMCHECKBOX Afraid, ApprehensiveEmotional State- Affect FORMCHECKBOX WNL FORMCHECKBOX Constricted FORMCHECKBOX Changeable FORMCHECKBOX Inappropriate FORMCHECKBOX Flat FORMCHECKBOX Full FORMCHECKBOX Blunted, unvaryingFacial Expression FORMCHECKBOX WNL FORMCHECKBOX Anxiety, fear, apprehension FORMCHECKBOX Sadness, depression FORMCHECKBOX Anger, hostility, irritability FORMCHECKBOX Elated FORMCHECKBOX Expressionless FORMCHECKBOX Inappropriate FORMCHECKBOX UnvaryingPerception: FORMCHECKBOX WNL Hallucinations- FORMCHECKBOX Tactile FORMCHECKBOX Auditory FORMCHECKBOX Visual FORMCHECKBOX Olfactory FORMCHECKBOX Command **Thought Content: FORMCHECKBOX WNLDelusions- FORMCHECKBOX None Reported FORMCHECKBOX Grandiose FORMCHECKBOX Persecutory FORMCHECKBOX Somatic FORMCHECKBOX Illogical FORMCHECKBOX Chaotic FORMCHECKBOX ReligiousOther Content- FORMCHECKBOX Preoccupied FORMCHECKBOX Obsessional FORMCHECKBOX Guarded FORMCHECKBOX Phobic FORMCHECKBOX Suspicious FORMCHECKBOX Guilty FORMCHECKBOX Thought broadcasting FORMCHECKBOX Thought insertion FORMCHECKBOX Ideas of referenceThought Process: FORMCHECKBOX WNL FORMCHECKBOX Incoherent FORMCHECKBOX Decreased thought flow FORMCHECKBOX Blocked FORMCHECKBOX Flight of ideas FORMCHECKBOX Loose FORMCHECKBOX Racing FORMCHECKBOX Chaotic FORMCHECKBOX Concrete FORMCHECKBOX TangentialIntellectual Functioning: FORMCHECKBOX WNL FORMCHECKBOX Lessened fund of common knowledge FORMCHECKBOX Impaired concentration FORMCHECKBOX Impaired calculation abilityIntelligence Estimate - FORMCHECKBOX Develop. Disabled FORMCHECKBOX Borderline FORMCHECKBOX Average FORMCHECKBOX Above average FORMCHECKBOX No formal testingOrientation: FORMCHECKBOX WNL Disoriented to: FORMCHECKBOX Time FORMCHECKBOX Place FORMCHECKBOX PersonMemory: FORMCHECKBOX WNL Impaired: FORMCHECKBOX Immediate recall FORMCHECKBOX Recent memory FORMCHECKBOX Remote memory FORMCHECKBOX Short Attention SpanInsight: FORMCHECKBOX WNL FORMCHECKBOX Difficulty acknowledging presence of psychological problems FORMCHECKBOX Mostly blames other for problems FORMCHECKBOX Thinks he/she has no problemsJudgment: FORMCHECKBOX WNL Impaired Ability to Make Reasonable Decisions: FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe** Past Attempts to Harm Self or Others: FORMCHECKBOX None Reported FORMCHECKBOX Self** FORMCHECKBOX Others** Self Abuse Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Cutting** FORMCHECKBOX Burning** FORMCHECKBOX Other: FORMTEXT ?????Suicidal Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Passive SI** FORMCHECKBOX Intent** FORMCHECKBOX Plan** FORMCHECKBOX Means** Aggressive Thoughts: FORMCHECKBOX None reported FORMCHECKBOX Intent** FORMCHECKBOX Plan** FORMCHECKBOX Means**Comments: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors) Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) FORMTEXT ?????Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions) FORMTEXT ?????Financial/Employment/Education: (Examples: graduated HS, attended college, currently working, hx of working, multiple work skills) FORMTEXT ?????Health: (Examples: consistent good health, exercises regularly, self cares for health issues as directed by physician, eats nutritional foods) FORMTEXT ?????Leisure/Recreational/Community Involvement: (Examples: plays a sport, belongs to social group, attends gym, volunteers for Red Cross) FORMTEXT ?????Natural Supports: (Examples: Family members, clergy, close friends, neighbors, advisors) FORMTEXT ?????Spirituality/Culture/Religion: (Examples: enjoys religious services, participates in cultural events, meet regularly with rabbi) FORMTEXT ?????Assessed Needs Checklist Including Functional DomainsActivities of Daily LivingCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX Housekeeping/Laundry FORMCHECKBOX FORMCHECKBOX Money Management FORMCHECKBOX FORMCHECKBOX Transportation FORMCHECKBOX FORMCHECKBOX Housing Stability FORMCHECKBOX FORMCHECKBOX Personal Care Skills (includes Grooming/ Dress) FORMCHECKBOX FORMCHECKBOX Problem Solving Skills FORMCHECKBOX FORMCHECKBOX Grocery Shopping/ Food Preparation FORMCHECKBOX FORMCHECKBOX Exercise FORMCHECKBOX FORMCHECKBOX Time Management FORMCHECKBOX FORMCHECKBOX Medication Management FORMCHECKBOX FORMCHECKBOX Safety/Self Preservation FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Family and Social SupportsCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX Communication Skill FORMCHECKBOX FORMCHECKBOX Family Education (Directed at the exclusive well being of the person served) FORMCHECKBOX FORMCHECKBOX Peer/ Personal Support Network FORMCHECKBOX FORMCHECKBOX Community Integration FORMCHECKBOX FORMCHECKBOX Family Relationships FORMCHECKBOX FORMCHECKBOX Social/ Interpersonal Skills FORMCHECKBOX FORMCHECKBOX Caretaker Obligation Issues FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????LegalCN = Current Need AreaPD = Person Desires Change NowCNPDCNPD FORMCHECKBOX FORMCHECKBOX Legal Issues FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Employment/ Education/ FinancesCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX Education FORMCHECKBOX FORMCHECKBOX Employment/ Volunteer Activities FORMCHECKBOX FORMCHECKBOX Meaningful Activities FORMCHECKBOX FORMCHECKBOX Financial/Benefits (include VA benefits) FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Addictive Behavior and Substance Use CN = Current Need AreaPD = Person Desires Change NowCNPDCNPD FORMCHECKBOX FORMCHECKBOX Substance Use/ Addiction (Tobacco, illicit & licit drugs) FORMCHECKBOX FORMCHECKBOX Other Addictive Behaviors (food, gambling, exercise, sex etc.)Current Needs Selected Above as Evidenced By: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Mental Health/ Illness Management-Behavior ManagementCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX Dissociation FORMCHECKBOX FORMCHECKBOX Lack of Assertiveness FORMCHECKBOX FORMCHECKBOX Anger/ Aggression FORMCHECKBOX FORMCHECKBOX Disturbed Reality (Hallucinations) FORMCHECKBOX FORMCHECKBOX Mood Swings FORMCHECKBOX FORMCHECKBOX Antisocial Behaviors FORMCHECKBOX FORMCHECKBOX Disturbed Reality (Delusions) FORMCHECKBOX FORMCHECKBOX Obsessions FORMCHECKBOX FORMCHECKBOX Coping/ Symptom Management FORMCHECKBOX FORMCHECKBOX Gender Identity FORMCHECKBOX FORMCHECKBOX Oppositional Behaviors FORMCHECKBOX FORMCHECKBOX Cognitive Problems FORMCHECKBOX FORMCHECKBOX Grief/Bereavement FORMCHECKBOX FORMCHECKBOX Somatic Problems FORMCHECKBOX FORMCHECKBOX Compulsive Behavior FORMCHECKBOX FORMCHECKBOX Hyperactivity/Hypomania FORMCHECKBOX FORMCHECKBOX Stress Management FORMCHECKBOX FORMCHECKBOX Depression/Sadness FORMCHECKBOX FORMCHECKBOX Impulsivity FORMCHECKBOX FORMCHECKBOX Trauma FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Physical HealthCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX Health Practices FORMCHECKBOX FORMCHECKBOX Pain Management FORMCHECKBOX FORMCHECKBOX Sleep Problems FORMCHECKBOX FORMCHECKBOX Diet/Nutrition FORMCHECKBOX FORMCHECKBOX Sexual Health Issues FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????RiskCN = Current Need AreaPD = Person Desires Change NowCNPDCNPDCNPD FORMCHECKBOX FORMCHECKBOX High Risk Behaviors FORMCHECKBOX FORMCHECKBOX Suicidal Ideation FORMCHECKBOX FORMCHECKBOX Homicidal Ideation FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Other Need AreasCN = Current Need AreaPD = Person Desires Change NowCNPD FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Clinical Formulation – Interpretive SummaryThis Clinical Formulation is Based Upon Information Provided By (Check all that apply): FORMCHECKBOX Person Served FORMCHECKBOX Parent(s) FORMCHECKBOX Guardian(s) FORMCHECKBOX Family/Friend(s) FORMCHECKBOX Physician FORMCHECKBOX Records FORMCHECKBOX Law Enforcement FORMCHECKBOX Service Provider FORMCHECKBOX School Personnel FORMCHECKBOX Other: FORMTEXT ?????Interpretive Summary: What in your clinical judgment are the need areas, the factors that led to the needs, and your plan to address them? FORMTEXT ????? Further Evaluations Needed: FORMCHECKBOX None Indicated FORMCHECKBOX Psychiatric FORMCHECKBOX Psychological FORMCHECKBOX Neurological FORMCHECKBOX Medical FORMCHECKBOX Educational FORMCHECKBOX Vocational FORMCHECKBOX Visual FORMCHECKBOX Auditory FORMCHECKBOX Nutritional FORMCHECKBOX SU Assessment FORMCHECKBOX Other: FORMTEXT ?????Was Outcomes tool administered? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, specify: FORMTEXT ?????Diagnosis: FORMCHECKBOX DSM-IV Codes FORMCHECKBOX DSM 5 Codes FORMCHECKBOX ICD-9 Codes FORMCHECKBOX ICD-10 CodesCheck Primary/Billing Diagnosis CodeNarrative Description FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Prioritized Assessed Needs:AC-Active, PD-Person Declined, DF-Deferred, RE-Referred Out (If declined/deferred/referred out, please provide rationale)ACPD*DF*RE*1. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Person Does Not Want A Need Area Included In The IAP Or The Area Is Deferred/Referred Out Rationale(s)(Explain why Person Declined to work on Need Area; List rationale(s) for why Need Area(s) is/are Deferred/Referred Out below). FORMCHECKBOX None1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????Person’s Service Preferences, Level of Care/Indicated Services Recommendation: FORMTEXT ?????Person Served/Guardian/Family Response To Recommendations: FORMTEXT ?????Person’s Signature (Optional, if clinically appropriate)Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate):Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature:Date: FORMTEXT ?????Supervisor Signature (if needed):Date: FORMTEXT ?????Psychiatrist/MD/DO (If required):Date: FORMTEXT ?????Next Appointment:Date: FORMTEXT ?????Time: FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pm ................
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