BIO-PSYCHOSOCIAL ASSESSMENT



Chautauqua Healthcare Services

BIO-PSYCHOSOCIAL SELF ASSESSMENT

Chautauqua Healthcare Services wishes to provide you with the best services possible. In order to do so, we need to obtain the following information. This information will be used to assign you to the most appropriate program or therapist. Your assigned therapist will review this information with you to help develop your Treatment Plan. Thank you for your assistance.

Please be aware that this information is confidential with the following exceptions: (1) if you sign a Release of Information form; (2) upon receipt of a court order by a judge; (3) in the event of a valid emergency; (4) if you commit a crime at the program or against any person at the program, or threaten to commit such a crime; (5) upon suspicion of abuse or neglect; or (6) upon receipt of a request that may be governed by Florida Statutes, such as Workers Compensation. If there is information you don’t wish to write down, explain to your therapist during the interview.

Unless otherwise noted, all questions should be answered regarding the person who will be receiving services (for example: your child). If more space is needed, continue responses on back of page.

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|Name of person to receive services: ________________________________________ | |

|Date of Birth: ________________ Social Security #: _________________________ | |

|Other names used: ______________________________________________________ | |

|Name of person completing form: _________________________________________ | |

|Relationship to person receiving services: ___________________________________ | |

|Do you have a need for Assistive Technology (interpreter, verbal instructions, etc.) in the Provision of Services?     Yes    No | |

|If yes, Describe:__________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Do you have any other disabilities, disorders or concerns in this area? Yes No | |

|If yes, Describe:__ _______________________________________________________________ | |

|_______________________________________________________________________________ | |

|Who referred you to treatment? (Circle) | |

|Self Dept. Children & Families (DCF) Parents Family Member | |

|Physician School Work Other:_______________ | |

|Presenting Problem (include impact on social, work, and/or academic functioning): | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Are you experiencing problems of an emotional/behavioral nature? Yes No | |

|If yes, circle all that apply: | |

|Depression Generalized Anxiety Panic Attacks Post-Traumatic Stress | |

|Bipolar Mood Substance Abuse Obsessions Compulsions | |

|Delusions Hallucinations Distractibility Hyperactivity | |

|Other, describe: _________________________________________________________________ | |

|______________________________________________________________________________ | |

|If yes, describe current symptoms (when did they start? How severe? How frequent? How long?): | |

|______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Are you experiencing significant stressors? Yes No | |

|If yes, describe any current stressors and/or precipitating events: _________________________ | |

|_______________________________________________________________________________ | |

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|What do you know about the concept of “Recovery? ____________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Are you seeking change at this time? Yes No | |

|How motivated or hopeful are you about treatment, change, and the future? __________________ | |

|_______________________________________________________________________________ | |

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|What issues are important to you? Circle all that apply | |

|Meeting Probation Requirements Obtaining Driver’s License Reunification with Family | |

|Medication Management Coping with Stress Improving Relationships in Your Home | |

|Other, describe: _________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Are you currently in psychiatric treatment of any type? Yes No | |

|If yes, Describe current treatment (include type of treatment and providers, effectiveness, etc): | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Circle all that apply: | |

|Recent Hospitalization History of Hospitalization Relocation/Starting Services | |

|Referral from Private Therapist Referral from Physician | |

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|PAST PSYCHIATRIC TREATMENT | |

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|Have you ever been in the hospital for mental health treatment? Yes No | |

|If yes, number of psychiatric hospitalizations: ______ | |

|Have you ever been in outpatient care for mental health treatment? Yes No | |

|If yes, number of outpatient psychiatric admissions: ______ | |

|Have you ever been in a day treatment program? Yes No | |

|Have you ever been in a residential treatment center? Yes No | |

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|Name of Facility: Location: Reason for Treatment: Start-End Dates: How did you do?: | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|Did you have a positive experience in your previous treatment? Yes No | |

|Were you compliant with previous treatment? Yes No | |

|Comments about past psychiatric treatment? __________________________________________ | |

|_______________________________________________________________________________ | |

|History of psychiatric symptoms experienced in the past (symptoms, onset, severity, frequency, duration): | |

|______________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Circle all that apply | |

|History of Psychiatric Services History of Substance Abuse Services | |

|History of Counseling Services as a Child or Minor History of Counseling Services as an Adult | |

|History of Services for Violent Behaviors None | |

|Any history of thoughts/plans/acts/ideation or intention of suicide? Yes No | |

|If yes, circle all that apply: Passive Thoughts Single Attempt Multiple Attempts | |

|If yes, explain: __________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Do you currently have any thoughts/plans/acts/ideation or intention of suicide? Yes No | |

|If yes, describe: __________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|Any history of thoughts/plans/acts/ideation or intention of homicide? Yes No | |

|If yes, circle all that apply: Passive Thoughts Violence Towards Another | |

|If yes, explain: __________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Do you currently have any thoughts/plans/acts or intention of homicide? Yes No | |

|If yes, describe: _________________________________________________________________ | |

|_______________________________________________________________________________ | |

|If you answered yes to the above questions, what things happen that make you want to harm yourself or others? | |

|_______________________________________________________________ | |

|_______________________________________________________________________________ | |

|Do you feel that you are currently (within the past 6 months) at risk for Dangerous Behaviors? Yes No | |

|If yes, identify any situation that increases risk for dangerous behaviors: _____________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, how do you currently cope or deal with these risks? ________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, describe any warning signs related to the risks of dangerous behaviors:_________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

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|MEDICAL INFORMATION | |

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|Have you taken any medications in the last two weeks? Yes No | |

|Do you take any medications for any reason? Yes No | |

|Have you always taken your medications as prescribed in the past? Yes No | |

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|Medication History: | |

|Medications Taken (List All): | |

|Name: Dosage: Reason Prescribed and Date: Reason Ended and Date: | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

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|List any other medication not included above: _________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

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|Medical History: | |

|Medical History: Circle all that apply: | |

|Breathing Problems Diabetes High Blood Pressure High Cholesterol | |

|Heart Problems Impaired Ability to Walk Infectious Disease Impaired Hearing | |

|Impaired Speech Impaired Vision Liver Problems MR/DD/LD | |

|Obesity Seizure Disorder Ulcer GI Problems | |

|Other:__________________________________________________________________________ | |

|Do you currently have Tuberculosis (TB)? | |

|Have you ever been diagnosed with Tuberculosis (TB) in the past? | |

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|Comments regard medical history: ___________________________________________________ | |

|________________________________________________________________________________ | |

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|Number of pregnancies: ____ Number of Live Births: _____ Birth Control? Yes No | |

|Birth control method (protection during sex):___________________________________________ | |

|Any allergies or special precautions? Yes No Unknown | |

|If yes, circle all that apply: | |

|Seasonal Medications Food Latex Animals Other | |

|If yes, specify: _________________________________________________________________ | |

|______________________________________________________________________________ | |

|Do you have any special nursing/medical needs? Yes No | |

|If yes, circle all that apply: | |

|Walking Home Health Monitoring Nursing Home Dialysis | |

|Clinic Visits/Injections Oxygen/Portable Oxygen Pacemaker Other | |

|If yes, specify: _________________________________________________________________ | |

|______________________________________________________________________________ | |

|Do you experience limitations due to physical health or disability? Yes No | |

|If yes, circle all that apply: | |

|Lifting Not Able to Work Strenuous Activities Other | |

|If yes, explain: _________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Name of personal physician: _______________________________________________________ | |

|Phone number: ________________________________________________________ | |

|Treating facility: _________________________________________________________ | |

|Release of Information completed to coordinate care? Yes No Unknown N/A | |

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|SUBSTANCE USE | |

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|Do you have any history of tobacco use? Yes No | |

|Do you have any history of using drugs, alcohol, or other substances? Yes No | |

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|Drugs, Alcohol, or Substances Used (by preference, with #1 being most preferred): | |

|Substance: How Taken: Age Started: Frequency of use: Last Time Used: | |

|1._______________________________________________________________________________ | |

|2._______________________________________________________________________________ | |

|3._______________________________________________________________________________ | |

|4._______________________________________________________________________________ | |

|5._______________________________________________________________________________ | |

|6._______________________________________________________________________________ | |

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|DEPENDENCE | |

|Do you find yourself using more of your chosen substance? Yes No | |

|Do you suffer from withdrawal when you try to quit? Yes No | |

|Do you use to excess? Yes No | |

|Have you tried to cut down/control? Yes No | |

|Do you find yourself preoccupied with use? Yes No | |

|Has your use diminished your functioning? Yes No | |

|Have you continued to use despite negative consequences? Yes No | |

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|DOES (OR HAS) YOUR ABUSE: | |

|Interfere with your daily life? Yes No | |

|Place you in hazardous situations? Yes No | |

|Cause you legal problems? Yes No | |

|Cause you interpersonal conflict? Yes No | |

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|How many days per week do you have more than 2 alcoholic drinks? ____________________ | |

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|OTHER ADDICTIONS | |

|GAMBLING | |

|Any history of gambling? Yes No | |

|If yes, Describe: _______________________________________________________________ | |

|Do you feel you may have a gambling problem? Yes No | |

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|SEX | |

|Any history of sexual acting out, pornography, sex crimes, legal charges, harmful behaviors, etc.? Yes No | |

|If yes, Describe: _______________________________________________________________ | |

|Do you feel you may have a possible sex addiction? Yes No | |

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|FOOD | |

|Any history of overeating, restricting, and/or purging food? Yes No | |

|If yes, Describe: _______________________________________________________________ | |

|Do you feel you may have an eating disorder? Yes No | |

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|OTHER ADDICTION CONCERNS (internet, video games, social media, shopping, etc.) | |

|Please describe: _________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|MILITARY HISTORY | |

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|Have you ever served in the military? Yes No Are you currently serving? Yes No | |

|If yes, what branch? _____________________________________________________________ | |

|If yes, type of discharge (Circle): Honorable Dishonorable General Other N/A | |

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|If yes, Circle all that apply: | |

|Positive Military Experience Experienced Combat Situations | |

|No Traumatic Experiences Experienced Traumatic Events | |

|AWOL Injury/ Disability from Experience | |

|Other comments on the experience, any trauma, etc.: ___________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|TRAUMATIC EVENTS | |

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|Any current or past experience of being abused or neglected: Yes No | |

|If yes, circle all that apply: | |

|Emotional Abuse Neglect Physical Abuse | |

|Sexual Abuse Verbal Abuse Domestic Violence | |

|Witnessed Domestic Violence Witnessed Abuse Other:_________________ | |

|If yes, describe the above or any other traumatic experience: _____________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|Have you received services for past abuse? Yes No N/A | |

|If no, would you be interested in receiving services? Yes No N/A | |

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|FAMILY | |

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|Describe your family group (primary caregivers, siblings, birth order): _____________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Describe your childhood and adolescence (atmosphere, location, significant events). | |

|Circle all that apply: | |

|Parents Divorced Parents Separated Parents Remarried | |

|No Involvement of Biological Parents Parent(s) Deceased Raised by Grandparents | |

|Raised by Others Good/Happy Home Strict Home | |

|Religious Home Unfair Home Abusive Home | |

|Absent Family Multiple Homes Other | |

|Explain:_________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Are significant issues from childhood impacting current presenting problem? Yes No | |

|If yes, Circle all that apply: | |

|Trust Issues with Current Relationships Intrusive Memories | |

|Difficulty with Activities of Daily Living Ongoing Tense Relationships with Family | |

|Difficulty with Academic/School Functioning Loss of Family with Residual Feelings | |

|Explain: __________ _____________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Describe which family members are living, where, contact, relationships: ___________________ | |

|_______________________________________________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Do you have a positive relationship with your parents? Yes No | |

|Do you have a positive relationship with your siblings? Yes No | |

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|Have any family members had a history of Mental Illness: Yes No | |

|If yes, what relationship are they to you? (Biological parent, half-sibling, spouse, etc.)_ _________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, describe illness (give diagnosis if known). Circle all that apply: | |

|Depression Bipolar Anxiety Schizophrenia | |

|Suicides ADHD Mental Retardation | |

|Other: __________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Family History of Substance Abuse? Yes No | |

|If yes, what relationship are they to you? (Biological parent, half-sibling, spouse, etc.)_ _________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, Circle all that apply: Alcoholism Drug Use Substance Use | |

|If yes, explain: ___________________________________________________________________ | |

|________________________________________________________________________________ | |

|Family History of Criminal Activity? Yes No | |

|If yes, what relationship are they to you? (Biological parent, half-sibling, spouse, etc.)_ _________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, explain: ___________________________________________________________________ | |

|________________________________________________________________________________ | |

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|Family History of Violent Behavior? Yes No | |

|If yes, what relationship are they to you? (Biological parent, half-sibling, spouse, etc…) _________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, explain: ___________________________________________________________________ | |

|________________________________________________________________________________ | |

|Family History of Medical Problems? Yes No | |

|If yes, what relationship are they to you? (Biological parent, half-sibling, spouse, etc.)_ _________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If yes, Circle all that apply: Heart Problems Diabetes Cancer Other | |

|If yes, explain: ___________________________________________________________________ | |

|________________________________________________________________________________ | |

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|INTIMATE RELATIONSHIPS AND CURRENT LIVING SITUATION | |

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|Current marital status: __________________ Number of times married: _________ | |

|If married (or in a significant relationship) more than once, explain reasons for each | |

|divorce or separation: ___________________________________________________________ | |

|______________________________________________________________________________ | |

|Current problems with intimate relationships? Yes No | |

|Describe relationship with current partner. Circle all that apply | |

|Positive Negative Abusive Other N/A | |

|Comments: ______________________________________________________________________ | |

|________________________________________________________________________________ | |

|Sexual issues of concern. Circle all that apply | |

|None No Intimacy Not Emotionally Connected | |

|Medical/Physical Problems Low Libido Hypersexual | |

|Other: __________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Current living arrangement: ________________________________________________________ | |

|Number of persons, other than you, living in the home: ______ | |

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|List Household Members: | |

|Name: Relationship: Age: Gender: | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|_______________________________________________________________________________ | |

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|Do you need food, clothing, or shelter? Yes No | |

|Condition of home. Circle all that apply: In good condition In need of repair N/A | |

|How many times has your residence changed in the last two years? _____________ | |

|Current home atmosphere. Circle all that apply: | |

|Abusive Cold Closed Competitive Cooperative | |

|Crowded Distant Flexible Helpful Open | |

|Rigid Religious Warm Other:__________________________ | |

|Current living situation. Circle all that apply: | |

|Adequate Homeless Overcrowded Unstable Other | |

|Describe: _______________________________________________________________________ | |

|________________________________________________________________________________ | |

|Are you satisfied with your current living situation? Yes No | |

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|Do you have children? Yes No | |

|If yes, give names and ages, where children live, and describe relationships with children: | |

|________________________________________________________________________________________________________________________________________________| |

|________________ | |

|________________________________________________________________________________ | |

|Are you able to form and maintain relationships? Yes No | |

|Overall quality of interpersonal relationships Circle all that apply: | |

|Adequate Relationships Adequate Social Supports Conflicts with Relationships | |

|Describe (length, amount of difficulty forming and maintaining): ___________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Are there family issues to be addressed in treatment? Yes No | |

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|CULTURAL, GENDER, AND SPIRITUAL CONSIDERATIONS | |

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|Do you identify with a particular cultural group? Yes No | |

|If yes, describe group: __________________________________________________________ | |

|_____________________________________________________________________________ | |

|Any Gender and/or Sexual Orientation Issues? Yes No | |

|If yes, describe issues: __________________________________________________________ | |

|_____________________________________________________________________________ | |

|Primary Religious Affiliation Circle any that apply: | |

|Baptist Buddhist Catholic Episcopalian Hindu | |

|Lutheran Methodist Muslim Non-denominational Protestant | |

|Unknown Other Non-Christian None Other-Christian | |

|Other: ________________________________________________________________________ | |

|Describe religious or spiritual beliefs and practices: ___________________________________ | |

|______________________________________________________________________________ | |

|______________________________________________________________________________ | |

|How often are you involved in religious or spiritual practices? Circle all that apply | |

|Regular Involvement Occasional Involvement | |

|Special Celebrations/Holiday Involvement No Involvement | |

|Do you have spiritual strengths? Yes No | |

|Do you have spiritual problems? Yes No | |

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|EDUCATIONAL AND DEVELOPMENTAL INFORMATION | |

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|Do you have any problems of an academic nature? Yes No | |

|Are you currently in school/college/training program? Yes No | |

|If so, name of school/college/training program: ________________________________________ | |

|Location of school (city): _________________________________________________________ | |

|Highest grade completed: _________________________________________________________ | |

|Were you in special education classes? Yes No Unknown | |

|Describe how you did in school. Circle all that apply: | |

|Good/Decent Grades Fair/Poor Grades Retained | |

|Learning Disability No Behavior Issues Some Behavior Issues | |

|Frequent Behavior Issues Suspended/Expelled Dropped out | |

|Other: _________________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Can the client read and write? Yes No Unknown | |

|Any difficulties with reading, writing, and/or comprehending? Yes No Unknown | |

|If yes, explain: ___________________________________________________________________ | |

|________________________________________________________________________________ | |

|Do you have a history of developmental delay? Yes No | |

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|If yes, circle all that apply: | |

|Bedwetting Delayed Walking Delayed Talking Toilet Trained Late Other | |

|If yes, specify: _______________________________________________________________ | |

|____________________________________________________________________________ | |

|Do you have qualities that could be academic strengths? Yes No | |

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|VOCATIONAL INFORMATION | |

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|Current employment status. (Circle): | |

|Active Military Criminal Inmate Disabled | |

|Employed Full-Time Employed Part-Time Full-Time Student | |

|Retired Unemployed--Not Seeking Unemployed--Seeking | |

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|How long at current job? 0-6 months 6 months–1 year 1-5 years 6-10 years over 10 years | |

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|Do you have problems of a vocational nature? Yes No | |

|Are you satisfied with your current job? Yes No | |

|Have you experienced difficulty performing work or work-like activity? Yes No | |

|If yes, Circle all that apply | |

|On Disability Applied for Disability Difficulty Maintaining Jobs | |

|No Work History Difficulty with Social Work Interactions Medical Problems Interfere | |

|Describe the severity/frequency of work problems of any kind: ____________________________ | |

|_______________________________________________________________________________ | |

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|Work History (List Current or Most Recent First): | |

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|Employer: Start/End Dates: Duties, Performance, Strengths/Problems: | |

|______________________________________________________________________________________ | |

|______________________________________________________________________________________ | |

|______________________________________________________________________________________ | |

|______________________________________________________________________________________ | |

|______________________________________________________________________________________ | |

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|FINANCIAL STATUS | |

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|Source of income or support received during the last 12 months: Circle all that apply | |

|Children Disability Illegal Activity Loans | |

|None Parents Retirement Social Security | |

|Spouse/Significant Other Wages Other:___________________________ | |

|________________________________________________________________________________ | |

|Do you currently have financial problems? Yes No | |

|If yes, Circle all that apply: | |

|Currently Unemployed Numerous Medical Problems/Bills Cannot Afford Medications Difficulty Paying Bills | |

|Difficulty Paying Utilities Possible Homelessness Owing/Paying Child Support Legal/Probation Fees | |

|Other | |

|If yes, explain: __________________________________________________________________ | |

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|LEGAL HISTORY | |

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|Have you ever been arrested? Yes No | |

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|Do you have any present legal involvement: Yes No | |

|If yes, Circle all that apply: | |

|Arrested, Not Convicted Assault Awaiting Sentence Awaiting Trial | |

|Convicted, Served Time Currently in Jail Currently in Prison Deferred Adjudication Deferred Prosecution | |

|Drug/Alcohol Offense On Bail On Parole | |

|On Probation Sex Offender Other:______________________________ | |

|Explain:________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Do you have any past legal involvement: Yes No | |

|If yes, Circle all that apply: | |

|Arrested, Not Convicted Assault Awaiting Sentence Awaiting Trial | |

|Convicted, Served Time Currently in Jail Currently in Prison Deferred Adjudication Deferred Prosecution | |

|Drug/Alcohol Offense On Bail On Parole | |

|On Probation Sex Offender Other:______________________________ | |

|Explain:________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Reason for last incarceration, when and how long: ______________________________________ | |

|_______________________________________________________________________________ | |

|________________________________________________________________________________ | |

|Are you presently awaiting charges, trial or sentence? Yes No | |

|If yes, explain: ___________________________________________________________________ | |

|_______________________________________________________________________________ | |

|Last arrested for (offense): ______________________________________ Date: ____________ | |

|Is there current DCF involvement? Yes No | |

|If yes, describe: __________________________________________________________________ | |

|________________________________________________________________________________ | |

|Has there been any history of DCF involvement? Yes No | |

|If yes, describe: __________________________________________________________________ | |

|________________________________________________________________________________ | |

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|STRENGTHS/WEAKNESSES | |

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|Please list your strengths: Circle all that apply: | |

|Affectionate Ambitious Artistic Athletic Brave Calm | |

|Cheerful Considerate Creative Dependable Drug-free Easy-Going | |

|Efficient Energetic Forgiving Humorous Hardworking Insightful | |

|Honest Humble Independent Intelligent Kind Likeable | |

|Loyal Mature Open-minded Organized Outgoing Patient | |

|Active Attractive Healthy Strong Tough Prayerful | |

|Professional Reflective Relaxed Religious Reserved Resourceful | |

|Responsible Sensitive Serious Stable Sympathetic Tactful | |

|Adventurous Tolerant Trustworthy Warm Wholesome Wise | |

|Other:__________________________________________________________________________ | |

|Please list your needs:____________________________________________________________ | |

|________________________________________________________________________________________________________________________________________________| |

|________________ | |

|Please list your abilities: __________________________________________________________ | |

|________________________________________________________________________________________________________________________________________________| |

|________________ | |

|Do you have any preferences regarding services you receive (for example: male therapist; female therapist; Group therapy; evening; etc? | |

|Yes No | |

|If yes, describe:___________________________________________________________________ | |

|________________________________________________________________________________ | |

|Describe any leisure activities or hobbies: Circle all that apply | |

|Hunting/Fishing Spending Time with Family Playing on the Computer Church Activities Reading Cooking | |

|Working Outside Shopping | |

|Exercising Home Improvement Water Activities Other | |

|Comments:_________________________ _____________________________________________ | |

|________________________________________________________________________________ | |

|________________________________________________________________________________ | |

|If services are needed outside of Chautauqua Healthcare Services, do you have preferences as to where you are referred? | |

|Yes No | |

|If yes, describe: __________________________________________________________________ | |

|________________________________________________________________________________ | |

|Who makes up your current support system? Circle all that apply: | |

|Boy/Girlfriend Spouse/Partner Coworkers Extended Family | |

|Friends Immediate Family None Religious Organization | |

|Self-help Group Social Service Group Teachers Other:____________________ | |

|________________________________________________________________________________ | |

|Would you describe your current support system as adequate for your needs? Yes No | |

|Are there any barriers or challenges to treatment and to change? Yes No | |

|If yes, circle all that apply | |

|Anger Aggression Childcare Cultural Beliefs | |

|Family Members High Anxiety Unstable Living Conditions Medical Complications | |

|Memory Impairment Pregnancy Past Treatment Experience Religious Beliefs | |

|Severe Depression Substance Use Medication Side Effects Transportation | |

|Work Schedule Other: ______________________________________________________ | |

|Explain: ________________________________________________________________________ | |

|________________________________________________________________________________ | |

|What goals do you want to accomplish during treatment? Circle all that apply: | |

|Meet Legal Requirements Complete Case Plan Get Stabilized on Medication | |

|Increase Symptom Management Increase Coping Skills Other: __________________ | |

|Explain: _______________________________________________________________________ | |

|________________________________________________________________________________ | |

|Do you want your family involved in your treatment? Yes No | |

|If yes, describe:___________________________________________________________________ | |

|________________________________________________________________________________ | |

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|If you are experiencing concerns with DEPRESSION, please check the appropriate areas below: | |

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|(Check all that apply. If you want to accomplish goals that are not listed, please write in goals in the space listed as other.) |

| | | | | | | |√ ( Check all that apply) |

|I Will Shower |  |  |  |  | |  | |

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|have established on my treatment plan. |  | |  | |

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|If you are experiencing concerns with Substance Abuse issues, | | | |

|please check the appropriate areas below: | | | |

|(Check all that apply. If you want to accomplish goals that are not listed, please write in goals in the space listed as other.) |

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|established on the treatment plan. |  |  | |  | |

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STOP HERE PLEASE

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|MENTAL STATUS EXAM – BIO-PSYCHOSOCIAL EVALUATION - ADULT |

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|Name: _____________________________________________ Date: __________________________ |

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|Reason for exam: _____________________________________________________________________________________ |

|____________________________________________________________________________________________________ |

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|Section 1: HISTORY |

|Description of illness for current treatment episode: __________________________________________________________ |

|____________________________________________________________________________________________________ |

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|Potential organic behavioral symptoms observed by others or reported by client: |

|__None __Unusual or bizarre behavior |

|__Evidence of poor social judgment __Attention and/or concentration problems |

|__Language problems __Reading, writing and calculation difficulty |

|__Memory difficulty __Difficulty with geographic orientation |

|__Other: ____________________ |

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|Describe any potential organic symptoms: _________________________________________________________________ |

|____________________________________________________________________________________________________ |

|Delusions or paranoia in the past: ________________________________________________________________________ |

|____________________________________________________________________________________________________ |

|Hallucinations reported by others: _______________________________________________________________________ |

|____________________________________________________________________________________________________ |

|Current Hallucinations? Yes No If Yes, describe: ____________________________________________________ |

|____________________________________________________________________________________________________ |

|Other psychiatric symptoms in client’s history: _____________________________________________________________ |

|____________________________________________________________________________________________________ |

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|History of: |

|__Brain damage at birth __Neurologic disease __Central nervous system infections |

|__Significant head trauma __Seizures __Toxic exposure |

|__Recent surgery/anesthesia __Other medical disease/treatment |

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|MEDICAL HISTORY |

|See History Section |

|Comments: ________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Developmental Delay: |

|See History Section |

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|Education |

|See History Section |

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|Estimate client’s premorbid/baseline level of functioning: _________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Family history of neurologic, psychiatric, other disease process involving the CNS: _________________________________ |

|_____________________________________________________________________________________________________ |

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|Section 2: GENERAL BEHAVIORAL OBSERVATIONS |

|General appearance: ___________________________________________________________________________________ |

|Personal cleanliness: ___________________________________________________________________________________ |

|Habits of dress: _______________________________________________________________________________________ |

|Motor activity: ________________________________________________________________________________________ |

|Thought content/process: _______________________________________________________________________________ |

|Comments on general behavioral observations: ______________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Section 3: MOTIVATION, MOOD/AFFECT, LEVEL OF CONSCIOUSNESS |

|Does client appear to have adequate motivation and interest in this evaluation: |

|Yes No Can’t Determine |

|Rate the client’s state of consciousness at the time of this exam: |

|__ Alert: awake, fully aware, responsive |

|__ Lethargic: not fully awake, drifts off to sleep |

|__ Obtunded: confused, difficult to arouse |

|__ Stuporous: responds only to vigorous stimulation |

|__ Comatose: completely unarousable |

|Orientation: ___________________________________________________________________________________________ |

|Mood at the time of the exam: ____________________________________________________________________________ |

|Affect during the exam: _________________________________________________________________________________ |

|Comments about mood and/or affect: _______________________________________________________________________ |

|Indicate any factors that may negatively influence or interfere with performance: |

|__ Drug or medication effects __ Lack of sleep |

|__ Poor rapport __ Client uncooperative |

|__ Malingering __ Thought disorder |

|__ Low IQ __ Other: _______________________ |

|Comments about factors that may interfere with performance on this evaluation: ____________________________________ |

|_____________________________________________________________________________________________________ |

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|Section 4: ATTENTION |

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|WITHIN NORMAL LIMITS? YES NO |

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|Observations: |

|Having difficulty attending to examiner? Yes No |

|Attend to verbal stimulus: _____________________________________________________________________________ |

|Vigilance: _________________________________________________________________________________________ |

|Inattention to physical stimuli: _________________________________________________________________________ |

|Distractible? Yes No |

|Comments about attention: _______________________________________________________________________________ |

|______________________________________________________________________________________________________ |

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|Section 5: LANGUAGE |

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|WITHIN NORMAL LIMITS? YES NO |

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|Speech: ______________________________________________________________________________________________ |

|Rate: Increased Decreased Normal |

|Latency: Increased Decreased Normal |

|Tone: Soft Loud Normal |

|Comments about language: _______________________________________________________________________________ |

|______________________________________________________________________________________________________ |

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|Section 6: MEMORY |

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|WITHIN NORMAL LIMITS? YES NO |

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|Recent memory/orientation: |

|Ask “What is your name?” Answers Correctly Incorrect |

|Ask “How old are you?” Answers Correctly Incorrect |

|Ask “When is your birthday?” Answers Correctly Incorrect |

|Ask “Where are we right now?” Answers Correctly Incorrect |

|Remote memory: |

|Ask “Where were you born?” Answers Correctly Incorrect |

|Ask “Where did you go to school?” Answers Correctly Incorrect |

|Ask “What is your mothers’ maiden name?” Answers Correctly Incorrect |

|ask “Name several recent US Presidents” Answers Correctly Incorrect |

|ask “Name several recent US wars” Answers Correctly Incorrect |

|New-learning ability: |

|Number of words repeated back immediately: ________________________________ |

|Number of words recalled after 5 minutes of interference: ______________________ |

|Number of words recalled after 10 minutes of interference: _____________________ |

|Number of words recalled after 30 minutes of interference: _____________________ |

|Comments about memory: _______________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Section 7: HIGHER COGNITIVE FUNCTIONS |

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|WITHIN NORMAL LIMITS? YES NO |

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|Client’s understanding of current situation: __________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|Fund of acquired general information/knowledge: |

|Above Average Below Average |

|Manipulation of Information |

|Verbal role calculations: Correct Incorrect |

|Proverbs |

|Don’t cry over spilled milk. Concrete Semiabstract Abstract |

|A bird in the hand is worth two in the bush. Concrete Semiabstract Abstract |

|People in glass houses should not throw stones. Concrete Semiabstract Abstract |

|Verbal Similarities |

|How are broccoli and spinach alike? Incorrect Relative Abstract |

|How are a boat and a car alike? Incorrect Relative Abstract |

|How are a table and a desk alike? Incorrect Relative Abstract |

|How are a poem and a book alike? Incorrect Relative Abstract |

|How are an orange and a dog alike? Incorrect Relative Abstract |

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|Insight: Good Fair Poor |

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|Judgment: Intact Impaired |

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|Comments about higher cognitive functions: _________________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Section 8: SUMMARY OF FINDINGS |

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|Based on this evaluation: |

|_____________________________________________________________________________________________________ |

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|Section 9: DSM-5 / ICD-10 DIAGNOSIS |

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|Diagnostic Impression: |

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|Primary: ______________________________________________________ DSM 5 Code______________ ICD-10: ____________ |

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|Secondary ______________________________________________________ DSM 5 Code _____________ |

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|Tertiary: _________________________________________________________ |

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|IMPORTANT PSYCHOSOCIAL AND CONTEXTUAL FACTORS: _________________________________________________________________________________________________________ |

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|Current CGAS = _____________ Highest CGAS in last year: __________________ |

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|Section 10: RECOMMENDATIONS |

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|_____________________________________________________________________________________________________ |

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|____________________________________________ _________________________________________________ |

|Qualified Professional/Supervisor Date Staff/Clinician Signature Date |

|The diagnosis and treatment recommendations have been |

|reviewed and appear to be appropriate given the individual’s |

|condition at this time. |

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|INDIVIDUALIZED RECOVERY PLAN |

|(TENTATIVE) |

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|What are the client’s goals and preferences for treatment? Will there be family involvement? |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|Problems Identified How Problem is to be Addressed (Indicate if deferred and why) |

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|1. _______________________________________________ __________________________________________________________ |

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|2. _______________________________________________ __________________________________________________________ |

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|3. _______________________________________________ __________________________________________________________ |

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|4. _______________________________________________ __________________________________________________________ |

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|Identified educational needs: (Include where and how these needs will be addressed): _________________________________________ |

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|________________________________________________________________________________________________________________ |

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|________________________________________________________________________________________________________________ |

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|Barriers to Treatment Identified: (check only those that apply) |

|1Educational limitations 1Developmental delays 1Lacking Economic Resources 1Low Motivation |

|1Unemployment 1Transportation 1 Physical Problems 1Homelessness |

|1Limited Family/Social Support 1Limited Insight |

|1Other _______________________________________________________________________________________________________ |

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|Treatment Services/Modalities Recommended: (Include service, modality, and frequency. Include external referral): |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|Criteria for Discharge: |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

|_____________________________________________________________________________________________________ |

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|_______________________________________________ _____________________________________________________ |

|Client (or Guardian) Signature/Date Clinician Signature/Credentials//Date |

|I understand the purpose of this Treatment Plan. I was, and will |

|continue to be, involved in decisions regarding my treatment. |

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|_______________________________________________ |

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|Qualified Professional/Supervisor/ Signature/Credentials/Date |

|The diagnosis and treatment recommendations have been reviewed and appear to be appropriate given the individual’s condition at this time. |

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