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 Served/Family’s Own Words)Referral Source and Reason for Referral: FORMTEXT ?????What Occurred to Cause the Person to Seek Services Now (Note Precipitating Event, Symptoms, Behavioral and Functioning Needs): FORMTEXT ?????Custody (If more than one parent/guardian has custody, check all boxes that apply to indicate sole or joint legal and/or physical custody) FORMCHECKBOX Self: FORMCHECKBOX Person is 18 yrs. Or Older FORMCHECKBOX Mature Minor (16 – 18 yrs. Old) FORMCHECKBOX Parent / FORMCHECKBOX Guardian 1:Name: FORMTEXT ????? FORMCHECKBOX Legal Custody FORMCHECKBOX Physical Custody FORMCHECKBOX Parent / FORMCHECKBOX Guardian 2:Name: FORMTEXT ????? FORMCHECKBOX Legal Custody FORMCHECKBOX Physical Custody FORMCHECKBOX DCFCaseworker Name: FORMTEXT ????? FORMCHECKBOX Other (Describe): FORMTEXT ????? Is there a Rep Payee? FORMCHECKBOX Yes FORMCHECKBOX No; If yes, complete the Rep Payee section of the Legal Status AddendumIs a Conservatorship? FORMCHECKBOX Yes FORMCHECKBOX No; If yes, complete the Conservatorship section of the Legal Status AddendumIs there a need for a Legal Guardian, Rep Payee or Conservatorship that has not been met? FORMCHECKBOX No FORMCHECKBOX Yes / Explain: FORMTEXT ?????Instructions for Integration with CANS AssessmentCurrent Status is either captured below or in CANS Assessment. If CANS Assessment has been completed check here FORMCHECKBOX . If you have completed the CANS you do not need to complete the current information for those areas noted with an * if the current status is well documented in the CANS narrative. History of all areas must be described. If you have not completed the CANS complete all the following information. Comment should be included for any CANS score above a 1.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 Housing FORMCHECKBOX DYS Facility FORMCHECKBOX Other: FORMTEXT ????? At Risk of Losing Current Housing FORMCHECKBOX Yes FORMCHECKBOX No Satisfied with Current Living Situation FORMCHECKBOX Yes FORMCHECKBOX No Is Person 14 ? years or older? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, Complete Transition to Adulthood Addendum FAMILY( FORMCHECKBOX Genogram Attached / FORMCHECKBOX Ecomap Attached)Household Members (Name)Relationship to Person ServedAge FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Street Address (if different from the person’s served address listed on Personal Information Form): FORMTEXT ?????Relevant Family Members/Others not listed aboveRelationship to Person ServedAge FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*Family Functioning/Parent and Child Interaction/Relationship Permanence: Include the child functioning within the context of his/her family and community.: Current Status FORMTEXT ????? History FORMTEXT ?????DEVELOPMENTAL INFORMATION*Developmental/Cognitive Delay and Functioning/Sensory/Motor/Sleep/Feeding Disorders: Include if child met developmental milestones and development/cognitive delay such as low IQ or developmental disability: Current Status FORMTEXT ????? History FORMTEXT ?????Learning Style (visual, auditory, verbal, written or learn by doing): FORMTEXT ?????Current Status FORMTEXT ????? History FORMTEXT ?????*Learning Disability/Communication, Comprehension and Expression: Include expressive and receptive language problems: Current Status FORMTEXT ????? History FORMTEXT ?????*School: Preschool/Childcare/Behavior/Achievement/Attendance: Provide information based on age of child, if older than preschool include current grade: Current Status FORMTEXT ????? History FORMTEXT ?????*Self Care: Include whether child can perform age appropriate activities of daily living, assistive technology and special communication needs and ability to self-preserve: Current Status FORMTEXT ????? History FORMTEXT ?????CULTURAL AND RELIGIOUS CONSIDERATIONS*Language (Primary Language and Secondary Language): Current Status FORMTEXT ????? History FORMTEXT ?????*Cultural Differences Within a Family: Current Status FORMTEXT ????? History FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????*Cultural/Ethnic Identity: Current Status FORMTEXT ????? History FORMTEXT ?????*Discrimination/Bias: Current Status FORMTEXT ????? History FORMTEXT ?????Religion/Spirituality: Current Status FORMTEXT ????? History FORMTEXT ?????*Youth/Family Relationship to System: Current Status FORMTEXT ????? History FORMTEXT ?????*Agreement About Strengths and Needs: Current Status FORMTEXT ????? History FORMTEXT ?????SOCIAL SUPPORT AND FUNCTIONING*Social Support, Social Functioning and Recreation/Play (Friendship/Social/Peer, Support Relationships, Afterschool Programs/Clubs, Pets, Community Supports/Self Help Groups such as AA, NA, SMART, NAMI, Peer Support, etc.) Include difficulties with social skills and relationships with peers and adults and child’s ability to play appropriately with peers): Current Status FORMTEXT ????? History FORMTEXT ?????)*Community Functioning: Current Status FORMTEXT ????? History FORMTEXT ?????EMPLOYMENT (complete if 14 years of age or older)Employment Income/Financial Support: FORMCHECKBOX Not Applicable 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 AddendumIncome/Financial Support (sources of and adequacy of financial support; own and/or parents/family): FORMTEXT ?????CAREGIVER RESOURCES AND NEEDS*Medical/Physical/Mental Health and Substance Abuse:Current Status FORMTEXT ????? History FORMTEXT ?????*Developmental/Cognitive Delay: Current Status FORMTEXT ????? History FORMTEXT ?????*Family Stress/Housing Stability/Financial Resources/Organizational Skills/Advocacy/Involvement: Current Status FORMTEXT ????? History FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????*Child/Youth Supervision: Current Status FORMTEXT ????? History FORMTEXT ?????Legal Involvement HistoryDoes the person have a history of, or current involvement with the legal system (i.e., legal charges)? FORMCHECKBOX No FORMCHECKBOX Yes; If yes, Please complete and attach the Legal Involvement and History AddendumTrauma HistoryDoes person report a history of trauma? FORMCHECKBOX No FORMCHECKBOX YesDoes person report history/current family/relevant other, household, and/or environmental violence, abuse or neglect or exploitation? FORMCHECKBOX No FORMCHECKBOX Yes If the answer to either of the above questions is yes, complete the Trauma History 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 completed the following based on the requirements of your program, funder, or organization: Check other assessments completed: FORMCHECKBOX GAIN FORMCHECKBOX CAGE FORMCHECKBOX AUDIT or FORMCHECKBOX Addictive Behavior/SA Addendum FORMCHECKBOX ESM/BSAS FORMCHECKBOX Other: 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 and course of illness): 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 ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Medical and Physical Health Summary OR FORMCHECKBOX Refer to Attached Physical Health AssessmentAllergies: FORMCHECKBOX No Known Allergies FORMCHECKBOX Yes, list below:Food: FORMTEXT ????? Medication Allergies and Medication Sensitivities (including OTC, herbal): FORMTEXT ????? Environmental: FORMTEXT ????? Medical and Physical Health Summary: Current: FORMTEXT ????? History (Health history including immunization status, prenatal exposure to alcohol and drugs, chronic conditions, significant dental history, and current physical complaints that may interfere with the person’s served functioning, issues of language, speech, hearing, vision, intellectual, sensory and motor development) : 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 ?????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 ?????*Sexuality. Include concerns with sexual development, sexual behavioral and concerns with sexual identity: Current: FORMTEXT ????? History/Concerns: 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 information and history of adverse reactions: (Include what medications 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 ????? If the person served is currently taking any medication, complete and attach the Medication Addendum.Primary Care Provider and Dentist Name and CredentialsAddressTel NumberFaxDate of Last Exam 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 ?????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 that help the client achieve his/her goals) Comment on all areasPersonal Qualities – Adaptable, Persistent, Curious, Playful, Creative, Confident, Optimistic, Resilient FORMTEXT ?????Living Situation, Family, and Interpersonal Relationships FORMTEXT ?????Financial/Employment/Education: FORMTEXT ?????Health: FORMTEXT ?????Leisure/Recreational/Community Involvement and Connections/Talents and Interests: FORMTEXT ?????Spirituality/Culture/Religion FORMTEXT ?????Assessed Needs Checklist Including Functional DomainsActivities of Daily LivingCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD 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 Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Family and Social SupportsCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD 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 ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????LegalCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFD FORMCHECKBOX FORMCHECKBOX Legal Issues FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Employment/ Education/ FinancesCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD FORMCHECKBOX FORMCHECKBOX Education FORMCHECKBOX FORMCHECKBOX Employment/ Volunteer Activities FORMCHECKBOX FORMCHECKBOX Meaningful Activities FORMCHECKBOX FORMCHECKBOX Financial/Benefits (include SSA, VA benefits) FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Addictive Behavior and Substance Use CN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFD 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 ?????Mental Health/ Illness Management-Behavior ManagementCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD FORMCHECKBOX FORMCHECKBOX Attachment FORMCHECKBOX FORMCHECKBOX Conduct FORMCHECKBOX FORMCHECKBOX Hyperactivity FORMCHECKBOX FORMCHECKBOX Atypical Behaviors FORMCHECKBOX FORMCHECKBOX Depression/Sadness FORMCHECKBOX FORMCHECKBOX Impulsivity FORMCHECKBOX FORMCHECKBOX Attention FORMCHECKBOX FORMCHECKBOX Dissociation FORMCHECKBOX FORMCHECKBOX Mania FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX Disturbed Reality (Hallucinations) FORMCHECKBOX FORMCHECKBOX Mood Swings FORMCHECKBOX FORMCHECKBOX Anger/Aggression FORMCHECKBOX FORMCHECKBOX Disturbed Reality(Delusions) FORMCHECKBOX FORMCHECKBOX Obsessions FORMCHECKBOX FORMCHECKBOX Antisocial Behaviors FORMCHECKBOX FORMCHECKBOX Emotional Control FORMCHECKBOX FORMCHECKBOX Oppositional/ Defiance FORMCHECKBOX FORMCHECKBOX Coping/Symptom Management Skills FORMCHECKBOX FORMCHECKBOX Eating Disturbance FORMCHECKBOX FORMCHECKBOX Somatic Problems FORMCHECKBOX FORMCHECKBOX Cognitive Delay FORMCHECKBOX FORMCHECKBOX Gender Identity FORMCHECKBOX FORMCHECKBOX Stress ManagementPerson’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Compulsive Behavior FORMCHECKBOX FORMCHECKBOX Grief/Bereavement FORMCHECKBOX FORMCHECKBOX Trauma FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Physical HealthCN = Current Need AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD 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 AreaPFD = Person/Family Desires Change NowCNPFDCNPFDCNPFD FORMCHECKBOX FORMCHECKBOX Bullying FORMCHECKBOX FORMCHECKBOX Homicidal Ideation FORMCHECKBOX FORMCHECKBOX Self-Mutilation FORMCHECKBOX FORMCHECKBOX Danger to Others FORMCHECKBOX FORMCHECKBOX Lack of Assertiveness FORMCHECKBOX FORMCHECKBOX Self-Harm FORMCHECKBOX FORMCHECKBOX Delinquent Behavior FORMCHECKBOX FORMCHECKBOX Running Away FORMCHECKBOX FORMCHECKBOX Sexual Aggression FORMCHECKBOX FORMCHECKBOX Exploited FORMCHECKBOX FORMCHECKBOX Poor Judgment FORMCHECKBOX FORMCHECKBOX Sexual Promiscuity FORMCHECKBOX FORMCHECKBOX Fire Setting Behavior FORMCHECKBOX FORMCHECKBOX Safety/ Self-Preservation Skills FORMCHECKBOX FORMCHECKBOX Sexualized Behaviors FORMCHECKBOX FORMCHECKBOX Frustration Tolerance/ Tantrums FORMCHECKBOX FORMCHECKBOX Sanction Seeking Behavior FORMCHECKBOX FORMCHECKBOX Suicidal Ideation/ Risk FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Current Needs Selected Above as Evidenced By: FORMTEXT ?????Other Need AreasCN = Current Need AreaPD = Person/ Family Desires Change NowCNPFD FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Other: FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: 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, symptoms that support your diagnosis, and your plan to address them? 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 ????? 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 SA Assessment FORMCHECKBOX Other: FORMTEXT ?????Was Outcomes tool administered? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, specify: FORMTEXT ?????Prioritized Assessed Needs: FORMCHECKBOX No Additional Recommendations Clinically IndicatedAC-Active, PD-Person Declined, F/G-Family/Guardian declined, DF-Deferred, RE-Referred Out (If person or family/guardian declined/deferred/referred out, please provide rationale)ACPD*F/G*DF*RE*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 Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Person or Family/Guardian Declined/Deferred/Referred Out Rationale(s)(Explain why Person Family/Guardian 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 ?????Will person’s family be involved with treatment FORMCHECKBOX Yes FORMCHECKBOX No. If yes, specify (include family’s response to recommendations, the involvement of family in the assessment process, state agency involvement and other supports).: FORMTEXT ?????Person’s Signature (Optional, if clinically appropriate) FORMTEXT ?????Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Psychiatrist/MD/DO (If required): FORMTEXT ?????Date: FORMTEXT ?????Next Appointment:Date: FORMTEXT ????? Time: FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmDate of ServiceProvider NumberLoc. CodePrcdr. CodeMod 1Mod2Mod3Mod4Start TimeStop TimeTotal TimeDiagnostic Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download