Biopsychosocial Annual Update 08 10 PP

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Biopsychosocial Annual Update 08 10 PP Powered By Docstoc
					                                        BIOPSYCHOSOCIAL ANNUAL UPDATE
  Insert Label or Indicate ALL Identifiers
  Client Name:
  Client ID#:
  Client D.O.B.
  Client RIN:

DATE:_______/________/________                       START TIME:_____________                    AM     PM       DURATION:___________ Min.
PHONE (HOME):                   (_____)_________-_____________                       PHONE (CELL):           (_____)_________-_____________
PHONE (WORK):                   (_____)_________-_____________                       EMAIL ADDRESS:
ADDRESS:
CITY:________________________________________________                                STATE:___________           ZIP:
FUNDING SOURCE:
  FULL-FEE   MEDICARE                            MEDICAID               MAN. CARE                EAP      INSURANCE               DASA/OASA
     NON-MEDICAID (Eligibility to be determined)                        OTHER FUNDING (Specify):

COMPLETED ASSESSMENT WITH:                            Client    Guardian/Family        Collateral:
                                                      Reviewed, explained, and signed consents and client’s rights with client and/or guardian

CLIENT PREFERENCES
Ask the following questions of the client to determine his/her strengths, personal goals and preferences. Ask the client to be as specific as possible and
ask for examples.
“What are your treatment goals? What are your treatment preferences? Which strengths can help achieve your goals?”




BARRIERS TO ACHIEVING CLIENT PREFERENCES
Barriers and Presenting Problems                     Extent of Problems              Nature of the Barriers and Problems:




CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)                               [X] REFER ALSO TO MENTAL STATUS EXAM
**     UNABLE TO ASSESS – MUST EXPLAIN WHY:


No check indicates symptom not present at this time
      Mild = Impacts quality of life, but no significant impairment of day-to-day functioning
      Moderate = Significant impact on quality of life and/or day-to-day functioning
      Severe = Profound impact on quality of life and/or day-to-day functioning

                                                CURRENT SYMPTOMS                                        HX OF SYMPTOMS
MOOD                                     Mild                Moderate               Severe
          Depressed mood
          Appetite disturbance
          Sleep disturbance
          Fatigue/low energy
          Psychomotor retardation
          Emotionality
          Flat affect
          Irritability/Agitation
          Anhedonia
          Hopelessness
          Poor grooming
          Guilt
Client Name                                                     Client ID #
                                        CURRENT SYMPTOMS            HX OF SYMPTOMS
MOOD                             Mild      Moderate    Severe
       Social isolation
       Worthlessness
       Grief
       Mood swings
       Elevated mood
       Comments:




ANXIETY
       Generalized anxiety
       Panic attacks
       Phobias
       Obsessions/compulsions
       Nightmares/Flashbacks
       Comments:




ADHD/COGNITIVE
       Hyperactivity
       Poor concentration
       Impulsivity
       Disorganized
       Disoriented
       Circumstantial symptoms
       Memory loss
       Learning problems
       Comments:




EATING DISORDERS
       Bingeing/purging
       Anorexia
       Laxative/diuretic abuse
       Comments:




PSYCHOTIC SYMPTOMS
       Paranoid ideation
       Dissociative states
       Loose associations
       Delusions
       Hallucinations
       Comments:




                                        CURRENT SYMPTOMS            HX OF SYMPTOMS
BEHAVIORAL ISSUES                Mild      Moderate    Severe
       Elimination disturbance
       Conduct problems
       Oppositional behavior
       Lying
       Manipulation
       Truancy
       Running away
2                                                                               Rev 8/2010
Client Name                                                                                                                     Client ID #
                                                                CURRENT SYMPTOMS                                                          HX OF SYMPTOMS
BEHAVIORAL ISSUES                               Mild                       Moderate                        Severe
             Property destruction
             Stealing
             Sexual acting out
             Cruelty to animals
             Fire setting
             Comments (must explain behavioral issues):




INDICATORS OF PERSONALITY DISORDER
             Describe any behavior/history that meets criteria for or suggests presence of a personality disorder :


DANGEROUS BEHAVIORS
    Must Complete Details for ALL items in Suicidal Ideation/Self-Mutilation(*) and /or Homicidal Ideation/Violent Behavior/Sexual Aggression/Anger Management Problem (**) sections.
                                                               Mild                       Moderate                       Severe                                History of Symptoms
             *Self-mutilation
             *Suicidal ideation
             **Homicidal ideation
             **Physical aggression
             **Extreme Anger Responses
             **Sexual aggression

*HISTORY OF/CURRENT SUICIDAL IDEATION/SELF-MUTILATION
                                               (Complete only if suicidal ideation/self-mutilation identified in symptom checklist – otherwise leave blank.)

Current/History of suicidal ideation and/or self-mutilation
Describe:




THOUGHTS: (As Described Above)
Suicidal                                                                                      Self-mutilation
   No thoughts of suicide                                                                        No thoughts of self-mutilation
   Active/current thoughts                                                                       Active/current thoughts
   Fleeting thoughts                                                                             Fleeting thoughts
   Thoughts within the last 7 days                                                               Thoughts within the last 7 days
   Continuous thoughts                                                                           Continuous thoughts
   Passive thoughts                                                                              Passive thoughts
PLANS:
Suicidal                                                                                      Self-mutilation
   No plans for suicide                                                                          No plans for self-mutilation
   Vague                                                                                         Vague
   No method reported                                                                            No method reported
     Specific organized plan – describe:




AVAILABILITY OF WEAPONS:
Suicidal behavior                                                                             Self-mutilation
   None                                                                                          None
   Difficult access                                                                              Difficult access
     Easy access – describe all relevant concerns:




3                                                                                                                                                                        Rev 8/2010
Client Name                                                                                                              Client ID #
ATTEMPTS:
Suicide - date of last attempt:                                                            Self-mutilation - date of last self-injury:
    No prior attempt                                                                         No prior self-mutilation
    Current                                                                                  Current
    Within last 7 days                                                                       Within last 7 days
    Historically – provide dates/times/descriptions for both concerns:




                                                 (See Risk Formulation for Details on How These Issues Are Addressed)
** HISTORY OF HOMICIDAL IDEATION/VIOLENT BEHAVIOR/SEXUAL AGGRESSION/ANGER MANAGEMENT PROBLEMS
                         (Complete only if homicidal ideation/violent behavior/sexual aggression/anger management problems identified in symptoms checklist – otherwise leave blank.)

Has ineffective anger control:
    No      Yes - If yes describe the anger level and intensity of the anger, the behavior when angry, and anger triggers:




Current impulses/thoughts about homicidal ideation/violent behavior/physical aggression/sexual aggression/assaultive behavior:
    No      Yes - If yes describe:




Current plans to act upon homicidal ideation/violent behavior/physical aggression/sexual aggression/assaultive behavior:
    No      Yes - If yes describe:




Has access to weapons to be used for homicidal ideation/violent behavior/physical aggression/sexual aggression/assaultive behavior:
    No      Yes - If yes describe:




Client history of homicidal ideation/violent behavior/physical aggression/sexual aggression/assaultive behavior:
    No      Yes - If yes describe:




Client has identified a specific plan for harming others:
    No      Yes - If yes describe:




4                                                                                                                                                                   Rev 8/2010
Client Name                                                                                          Client ID #
History of poor impulse control (check all that apply)
   Vandalism                                       School truancy                                                          Running away
   Verbal abusiveness                              Cruelty to animals                                                      Theft
   Gang membership                                 Fire setting                                                            Physical abusiveness
   Bedwetting (If age inappropriate)               Sexual acting out                                                       Property destruction
                                                (See Risk Formulation for Details on How These Issues Are Addressed)

CLIENT ABUSE/TRAUMA HISTORY/CURRENT
**      UNABLE TO ASSESS – MUST EXPLAIN WHY:



     No change since initial assessment
               Assessed - No Self-Reported History of Abuse/Violence/Neglect or Accusation Of (skip to immediate threats to personal safety)
                                        Victim                *Accused Of
                                                                                                        Received Treatment (Specify if Yes:)
 TYPE OF ABUSE/TRAUMA                     Yes       No        Check if Yes       Age(s)
                                                                                                           (If no: will be addressed in treatment)
 Emotional Abuse                                                                            Yes      No __________________________________
 Physical Abuse                                                                             Yes      No __________________________________
 Physical Neglect                                                                           Yes      No __________________________________
 Sexual Abuse/Molestation                                                                   Yes      No __________________________________
 Rape/Sexual Assault                                                                        Yes      No __________________________________
 Domestic Violence                                                                          Yes      No __________________________________
 Elder Abuse                                                                                Yes      No __________________________________
 Community Violence                                                                         Yes      No __________________________________
 Financial Exploitation                                                                     Yes      No __________________________________
 Other Trauma/Abuse                                                                         Yes      No __________________________________
 Specify Other:
Description of abuse/ violence/neglect/trauma experienced for all questions answered yes above (do not refer to perpetrator by name):




*Description of abuse/ violence/neglect/trauma accused of:




Any Immediate/Future Threats to Personal/Family Safety -                           None
  Gang involvement                Family violence                                          Physical abuse                              Community Violence
  Other:
    Note behavioral evidence for all items (include description of threat(s).




There Is a Current Order of Protection or Restraining Order For/Against Client:                             No         Yes - if yes, specify:



Needs/Issues/Services accessed/ Linkages needed -              NONE or explain/describe:




5                                                                                                                                     Rev 8/2010
Client Name                                                                                  Client ID #
MEDICAL HISTORY (check all that apply for client)            [X] REFER ALSO TO PHYSICAL HEALTH SCREEN
**     UNABLE TO ASSESS – MUST EXPLAIN WHY:



DATE OF MOST RECENT PSYCHIATRIC ASSESSMENT OR SERVICE:
Is there a history of any of the following:       No medical history or current concerns reported
    tuberculosis                            heart disease                 thyroid problems             diabetes                head injury
    high blood pressure                     cancer                        seizures                     stroke                  high cholesterol
    Alzheimer's disease/dementia            birth defects                 mental retardation           dental issue            nutritional issue
    sensory (vision/hearing/speech)         neurological                  genitourinary                gastrointestinal        respiratory
    contagious disease                      skeletal issues               muscle issues                TBI                     tremors
    Other medical issues not listed:
Primary Care Physician information: (* = required information)            Client has no Primary Care Physician – Requires Linkage
    *Name   of Physician and/or Practice:
    *Address:

    Phone Number:                                                               Fax Number:
    *Release   in chart:   Yes     No – If no, why not?:
Describe client self-report of current physical health:      Good      Fair    Poor     Other:

Last physical exam/Doctor visit: Date:                                Comments:


Any history of head injury or head trauma:         NONE or explain/describe:




Significant medical history (describe any serious hospitalization, injury, or accidents):        NONE or explain/describe:




List any non-psychotropic medications currently being taken including over the counter(give dosage & reason):
                                       If Yes:       Compliant w/ medication       Not compliant w/ medication
     NONE or explain/describe:




Physical pain assessment
    Is the client currently experiencing any physical pain?         Yes        No - If yes – what hurts:



    On a scale of 1 (no pain) to 10 (the worst pain experienced – unbearable) how painful does the client rate it:
    Frequency and description of the pain:




6                                                                                                                         Rev 8/2010
Client Name                                                                              Client ID #
Nutritional development
  normal
  malnutrition                    being underweight          binging            refusing foods                eating non-food items
  being overweight                hoarding food              purging            obese                         other:
What Medical Issues Contribute To Current Presenting Problem -                  NONE or explain/describe:




Needs/Issues/Services accessed/ Linkages needed -       NONE or explain/describe:




SUBSTANCE USE HISTORY/CURRENT (check all that apply for client)                     [X] TO BE COMPLETED FOR ALL MENTAL HEALTH CLIENTS


**      UNABLE TO ASSESS – MUST EXPLAIN WHY:



     No change since initial assessment
                     Assessed no history of use per client report - skip to family history of alcohol/drug abuse
Substances used:        See Alcohol/Drug Addendum         Current Use
(complete all that apply)       First use age Last use age (Yes/No) Frequency   Amount Use          Method            Longest time of abstinence
     caffeine
     nicotine/cigarettes
     alcohol
     amphetamines/speed
     cocaine
     crack cocaine
     ecstacy
     heroin
     opiates
     barbiturates/downers
     hallucinogens (e.g. LSD)
     inhalants (e.g. glue, gas)
     marijuana or hashish
     PCP
     prescription
     gambling
     over the counter
     other:_______________
Consequences of substance abuse (check all that apply):   See Alcohol/Drug Addendum
  no consequences reported
  loss of control amount used             hangovers                  withdrawal symptoms                      sleep disturbance
  truancy/academic failure                binges                     seizures                                 blackouts
  relationship conflicts                  overdose                   assaults                                 medical conditions
  job loss                                tolerance changes          arrests                                  suicidal impulse
  other
Treatment history:
   no treatment history
   stopped on own (age[s]                        )
   outpatient (age[s]                            )
   inpatient (age[s]                             )
   12-step program (age[s]                       )
   currently attends 12 step           times per week
   other (age[s]                                 )
   describe other:



7                                                                                                                        Rev 8/2010
Client Name                                                                                       Client ID #
Family alcohol/drug abuse history (per client report):             No change since initial assessment
   no family history of substance abuse
If history is present, list substances used:
    father:
    mother:
    sibling(s) :
    stepparent/live-in:
    grandparent(s) :
    spouse/significant other:
    children:
    uncle(s)/aunt(s):
    cousins:
    other (include substances used):
Needs/Issues/Services accessed/ Linkages needed -         NONE or explain/describe:




EDUCATIONAL DEVELOPMENT: assess all of the following using a developmental perspective in relation to normative development for chronological age

**     UNABLE TO ASSESS – MUST EXPLAIN WHY:


     No change since initial assessment
Last Grade Completed:                                 Name of Current/Last School Attended:
Elementary      -                   Did not attend elementary education                 Home schooled from                     to
        Attendance:                 excellent          good           fair               poor           truancy issues
        Grades:                     A                  AB             B                  BC             C                           CD          D             F
Secondary       -                   Did not attend secondary education                  Home schooled from                     to
        Attendance:                 excellent          good           fair               poor           truancy issues
        Grades:                     A                  AB             B                  BC             C                           CD          D             F
Post-secondary   -                  Did not attend post-secondary education
         Attendance:                excellent         good            fair                poor             truancy issues
         Grades:                    A                 AB              B                   BC               C                        CD          D             F
     GED Program – Where:                                                            Date Completed:
Any history of the following:
  none
  special education (IEP)           self-contained classroom      detention(s)                               expulsion(s)
  homebound tutoring                suspension(s)                 504 plan                                   speech therapy
  resource assistance               therapeutic day school        residential placement                       self-contained classroom
  occupational therapy              physical therapy              other:
If child was placed in or received Special Education, what were his/her eligibility category(ies):
    no special education placement or services
    autism                       deafness                   hearing impairment            multiple disabilities                     other health impairment
    traumatic brain injury       deaf-blindness             emotional disturbance         mental retardation                        orthopedic impairment
    specific learning disorder   visual impairment          speech/language               other:
Specialized training -         None identified           Client is a minor child
Or Describe:



Vocational skills -        None identified           Client is a minor child
Or Describe:




8                                                                                                                                   Rev 8/2010
Client Name                                                                                   Client ID #
Needs/Issues/Services accessed/ Linkages needed -         NONE or explain/describe:




SOCIO-ECONOMIC HISTORY(check all that apply for ALL clients)

**     UNABLE TO ASSESS – MUST EXPLAIN WHY:


Living situation:
   living situation stable
   private residence-client supervised                housing adequate                         other residential setting-client unsupervised
   private residence-client unsupervised              housing overcrowded                      other institutional setting
   homeless/undomiciled                               dependent on others for housing          state-operated facility
   lives in residential housing                       living companions dysfunctional          jail or correctional facility
   lives independently                                housing dangerous/deteriorating          emergency/transitional shelter
   lives with family                                  lives w/ foster family                   other:

Daily living skills:                         No change since initial assessment
   full self-care                                     partial-self-care                        unable to care for self
   client is capable to self medicate                 maintains personal hygiene               client is not capable to self medicate
   engages successfully in the community              inadequate resources
   maintains personal safety                          does not have literacy/basic math skills
   needs assistance                                   demonstrates coping skills/emotional management
   other:
Social support system:
   supportive network                                 few friends                              substance-use-based friends
   distant from family of origin                      no friends                               no support system
   other:


Sexuality current/history:                  No    change since initial assessment
   heterosexual orientation                           homosexual orientation                   bisexual orientation           transgender
   currently sexually active                          not sexually active                      sexual addiction issues
   minor child – no sexual behavior identified        other:
Military current/history:                     No change since       initial assessment
   never in military
   currently in military – branch of service:                                                years of service to date:                      Reserves
   served in military – branch of service:                                                   years of service to date:                      Reserves
       honorable discharge
       conditional discharge (Explain):
       dishonorable discharge (Explain):
       special circumstances related to military discharge:
     served in combat          When/Where:
                               Special circumstances related to combat:
Employment current/history:
  works full time                                     works part-time                          retired
  homemaker                                           unstable work history                    employed subsidized/supported
  other seasonal worker                               disabled                                 self-employed
  unemployed                                          supervisor conflicts                     coworker conflicts
  minor child - not in labor force                    student – not employed
  other:
      Past and current employment experience related to education and identified vocational skills, (specify):




9                                                                                                                             Rev 8/2010
Client Name                                                                                   Client ID #
Financial situation:
   no current financial problems                  receiving unemployment                      receiving SSI or SSDI
   poverty or below-poverty income                large indebtedness                          receiving housing subsidy
   receiving food subsidy                         receiving child support                     receiving alimony payments
   receiving financial subsidy                    receiving public entitlements:
   other:
Needs/Issues/Services accessed/ Linkages needed -     NONE or explain/describe:




LEGAL HISTORY/STATUS (check all that apply for ALL clients)
**      UNABLE TO ASSESS – MUST EXPLAIN WHY:



     No change since initial assessment
     no current/history of legal issues               mental health court                     drug court
     mandatory outpatient treatment                   probation current                       parole current
     guilty but mentally ill                          unfit to stand trial                    conditional release
     recently arrested                                awaiting trial                          recently incarcerated
     history of probation                             history of parole                       history of incarceration
     DCFS involvement (Specify):
     other:
     order of protection (Specify):
History of Arrests-Most Recent First (include age, offense, incarcerations etc.):



Probation Officer/Parole Agents Name and Contact Information:


Conditions of Probation/Parole etc.:


Needs/Issues/Services accessed/ Linkages needed -         NONE or explain/describe:


GUARDIANSHIP STATUS
**      UNABLE TO ASSESS – MUST EXPLAIN WHY:



     No change since initial assessment
     own guardian                            minor child – parent/guardian has guardianship                       DCFS guardianship
     mental health declaration               trust beneficiary                                                    pending court decision
     durable power of attorney for health care
     representative payee(name/address/contact number):

     Guardianship:     Plenary guardianship or Limited:            Guardianship of estate       Guardianship of person      Guardianship of medical
     Guardian Name:                                                                Telephone: (      )          -
     Address:
     documentation in chart to corroborate guardianship status (if required)



CULTURAL/SPIRITUAL/RECREATIONAL STATUS – MUST COMPLETE FOR ALL CLIENTS (check all that apply)
**      UNABLE TO ASSESS – MUST EXPLAIN WHY:


10                                                                                                                         Rev 8/2010
Client Name                                                                                           Client ID #

NOTE – WHEN COMPLETING THIS SECTION CONSIDER ALL OF THE FOLLOWING: Exploration of cultural identity
includes: related to family values, traditions, practices, race/ethnicity, age, gender, physical ability/disability, immigration, acculturation, sexual orientation,
indigenous heritage, national origin, religion, spirituality, educational background/level, and/or socioeconomic status. Any other cultural identity information not
noted here should be included if the client views the information as cultural in nature.
Who are the important people in your life?
Where do you go for support?
What are you good at and/or like to do?


What would you like to learn and/or do better at?


CULTURAL/ETHNIC IDENTITY:                                  No change since initial assessment
      Yes       No Do you identify with and/or feel connected to any particular cultural or ethnic group? - if yes* specify
      Yes       No Do you participate in any cultural activities?
  What aspects of your *culture and/or *ethnicity are meaningful to you?




  Describe any cultural issues that may contribute to challenges and issues:            None or describe:




  Describe the ways in which culture helps when faced with challenges and issues:                None or describe:



RELIGIOUS/SPIRITUAL BELIEFS:                               No change since initial assessment
      Yes       No Do you have a religious or spiritual belief system or orientation? - if yes, describe:
      Yes       No Do you currently participate in religious or spiritual belief activities? - if yes, how often:
  Describe any religious/spiritual beliefs/practices that may contribute to challenges and issues:             None or describe:




  Describe the ways in which religious/spiritual beliefs/practices help when faced with challenges and issues:                None or describe:



COMMUNITY INVOLVEMENT/HOBBIES/INTERESTS/USE OF SPARE TIME:                                                          No change since initial assessment
      Yes      No     Is client active in community/recreational activities? - If yes, describe:




  What are the clients hobbies and how do they typically spend their time when not working?;




CLIENT STRENGTHS AND BARRIERS TO RECOVERY

Strengths:                No change since initial assessment
   Accepts Guidance/Feedback                    Capable of Independence                     Clear Thinking                   Confident
   Expressive/Articulate                        Good Personal Care Habits                   Insightful                       Integrated Moral Values
   Intelligent                                  Motivated for Change                        Physically Healthy               Positive Support Network
   Reasonable Judgment                          Reliable                                    Responsible                      Sociable
   Stable Living Environment                    Stable Work History                         Supportive Family                Varied Interests

11                                                                                                                                      Rev 8/2010
Client Name                                                                                    Client ID #
  Other:
Barriers to recovery:            No change since initial assessment
  No barriers identified
  Concrete Thinking                        Defensive                                 Dependent                      Chaotic Living
  Distrustful                              Hostile                                   Illiterate                     Impulsive
  Indecisive                               Intellectual Deficits                     Irresponsible                  Lacks Insight
  Lacks Moral/Ethical Values               Lacks Social Skills                       Needs Close Supervision        Negative Peer Group
  No Support Network                       Non-Supportive Family                     Not Motivated to Change        Not Open/Articulate
  Poor Health/Chronic condition            Poor Hygiene/Grooming                     Poor Judgment                  Unreliable
  Unstable Employment History              Very Narrow Interests
  Other:

MENTAL STATUS EXAMINATION
 NOTE: The following are guidelines for the assessment of mental status and reflect information in the Biopsychosocial Assessment.

                                   appropriate grooming                       bizarre
                                                                                                                     disheveled
 Appearance                        untidy                                     normal posture
                                                                                                                     other:_____________________
                                   very neat                                  signs of anxiousness

                                   appropriate                                agitated                              bizarre
                                   assertive                                  mannerisms                            awkward
 Manner
                                   submissive                                 tics                                  compulsive
                                   restless                                   tearful                               other:_____________________
                                   cooperative                                guarded                               sarcastic
                                   uncooperative                              suspicious                            hostile
 Attitude
                                   friendly                                   ingratiating                          impressionable
                                   open                                       dejected                              other:_____________________
                                   alert
                                                                              stuporous
 Consciousness                     lethargic
                                                                              comatose
                                   confused
                                   appropriate                                labile
                                                                                                                    panic
                                   inappropriate                              anxious
 Affect (observable)                                                                                                soft, low voice
                                   flat                                       tearful
                                                                                                                    other:_____________________
                                   blunted                                    hostile

                                   normal                                     pessimistic                           hopeless
 Prevailing Mood                   elated                                     guilty                                anxious
                                   optimistic                                 depressed                             other:_____________________
                                                                                                                C. ASSOCIATIONS
                                                                          B. CONTENT
                                                                                                                   normal
                                                                             appropriate/normal
                                                                                                                   logical
                               A. RATE                                       delusional
                                                                                                                   relevant
                                  normal                                     somatic
                                                                                                                   goal directed
                                  retarded                                   persecutory
                                                                                                                   circumstantial
 Thought Processes                over-talkative                             ideas of reference
                                                                                                                   blocking
                                  difficulty in speech                       obsessions
                                                                                                                   nonsensical
                                  flight of ideas                            hypochondriasis
                                                                                                                   perseveration
                                  other                                      suicidal
                                                                                                                   inadequate
                                                                             homicidal
                                                                                                                   loose
                                                                             other:_________________
                                                                                                                   other:________________

                                   normal            spontaneous         delayed             soft                  loud            slurred
 Speech
                                   excessive         pressured           incoherent          perseverating         other:______________________

 Faculty Orientation               no impairment -or- impairment related to:                time        place        person



12                                                                                                                            Rev 8/2010
Client Name                                                                                        Client ID #
 Attention Span /                    normal             short              preoccupied             distractible
 Concentration
 Perception                         normal -or- hallucinations (check all that apply)               olfactory         visual         auditory

                                 A. Intelligence:         retarded            below average          average          above average           superior
                                 B. Fund of Information:               poor        average          superior
 Intellectual Functions
                                 C. Calculation:          normal           impaired
                                 D. Abstraction and Symbolization:                 normal          concrete thinking           personalized

                                     no impairment           immediate recall                  recent (short-term)             remote (long-term)
 Memory Deficits
                                     amnesia                 other:____________________________________________________________

 Judgment                            normal                  impaired
 Insight                            normal                   partial                           denial                          absent

SUICIDAL IDEATION AND HOMICIDAL IDEATION RISK FORMULATION (MUST COMPLETE FOR ALL CLIENTS)
Assessment of Level of Danger Toward Others
        Fully assessed – no indications of risk identified – skip to “Assessment of Level of Danger Toward Self”
        History of/current violence                                                     Poor anger control
        Substance abuse                                                                 History of/current poor impulse control
        Current psychotic symptoms including command hallucinations                     Anti-social features
        Childhood exposure directly or indirectly to violence                           Organic disorder that impedes self-control
        Current agitation                                                               Legal issues
        Serious environmental stressors or traumatic events                             Other:
     Level of dangerousness:            High           Moderate            Low
     Potential of harm toward others:          None –or- describe




     Other potential risks (i.e. sexual acting out, elopement, arson):        None –or- describe




     Required to act under duty to warn provision:          Yes        No - if yes, describe action(s) taken to protect other(s):




Assessment of Level of Danger Toward Self
        No concerns about danger toward self identified – skip to “Assessment of Risk Due to Inability to Care for Self”
        History of/current suicidal ideation                                                     Chronic illness and/or repeated accidents
        History of/current suicide attempt(s)                                                    History of/current depression
        Substance abuse                                                                          Organic disorder that impedes self-control
        Current psychotic symptoms including command hallucinations                              History of suicide by a family member or loved one
        History of/current poor impulse control and/or violence                                  Serious environmental stressors or traumatic events
        Legal issues                                                                             History of/current abuse or neglect victim
        Altered mental status                                                                    History of/current self-mutilation
        Unable to agree to an appropriate crisis plan                                            Other:
     Level of dangerousness:            High           Moderate            Low
     Potential of harm toward self:       None –or- describe




     Other potential risks (i.e. self-mutilation):     None –or- describe


13                                                                                                                                  Rev 8/2010
Client Name                                                                                                Client ID #


Assessment of Risk Due to Inability to Care for Self
        Fully assessed – no indications of risk identified – skip to “Intervention(s) Provided”
        Cognitive deficit                                                                                 Altered mental status
        History of/current TBI                                                                            Developmental disability diagnosis
        Substance abuse                                                                                   Organic disorder that impedes self-control
        History of/current poor impulse control and/or violence                                           History of/current depression
        Serious environmental stressors or traumatic events                                               Legal issues
        History of/current abuse or neglect victim                                                        History of suicide attempts
     Level of risk potential:              High             Moderate              Low
     Current psychotic or other symptoms/behaviors effecting self-care:                     None –or- describe:




     Chronic illness and/or repeated accidents as evidenced by:                  None –or- describe:




Intervention(s) Provided
Describe the steps taken to address client’s risk of harm to self or others including viable attempts to identify alternatives to hospitalization that were considered. Be
specific and clearly articulate the clinical plan for maintaining client and others safety including any data from the assessment relevant to the plan:
                  No crisis intervention is required – all areas were assessed and no risk was identified – skip to integrated summary
        Client provided with outpatient referral(s) - SEE LIST OF SERVICES
        Developed an appropriate Crisis Plan - SEE CRISIS PLAN
        CARES/SASS Assessment
        Psychiatric hospitalization
              Voluntary          Involuntary - Hospital/assessment unit client was sent to:
        Medical evaluation - Hospital/ER/detox unit client was sent to:
        Other:


Outcome of Crisis Services Provided (complete only if services were provided):




 INTEGRATED SUMMARY OF PRESENTING PROBLEMS (NATURE, EXTENT, and SEVERITY),
      SYMPTOMS, STRENGTHS, LEVEL OF FUNCTIONING, ANALYSIS, CULTURAL
   CONSIDERATIONS, and CONCLUSIONS (RECOMMENDED SERVICES IDENTIFIED IN NEXT SECTION)
    See Attached Typed Summary




14                                                                                                                                            Rev 8/2010
Client Name                                                                                   Client ID #




     See “PRELIMINARY TREATMENT PLAN/RECOMMENDED SERVICES INCLUDING ADDITIONAL EVALUATIONS/SERVICES” for assessment linked services.

Ability to participate in treatment:                                       excellent           good          fair           poor
Willingness to participate in treatment.                                   excellent           good          fair           poor
MENTAL HEALTH PRELIMINARY TREATMENT PLAN/RECOMMENDED SERVICES INCLUDING ADDITIONAL EVALUATIONS/SERVICES

                                            NO SERVICES RECOMMENDED – OPEN/CLOSE CASE

  CI: Crisis Intervention – To provide direct crisis intervention services to a client experiencing a psychiatric crisis.
  ITP: ITP Development/Review/Modification – Development, evaluate, and modify an ITP with targeted presenting

15                                                                                                                           Rev 8/2010
Client Name                                                                               Client ID #
        problem(s).
  T/C – Reduce negative impact of cognitive, emotional, and behavioral concerns associated with the presenting problem(s) and enhance
        development of effective self-management and coping skills to improve daily functioning.
  T/C Family – Address maladaptive pattern of interactions in order to decrease family and/or intimate relationship discord and to enhance
        family and/or intimate relationship relationships.
  T/C Group – Reduce negative impact of cognitive, emotional, and behavioral concerns associated with the presenting problem(s) and
        enhance development of effective self-management and coping skills to improve daily functioning.
  CM: Case Management - Mental Health – To improve community living and access to and using of community services.
  CCC: Case Management - Client Centered Consultation – Improve coordination of services through communication.
  LOCUS: Case Management – LOCUS – Completion of a LOCUS assessment with client.
  CS-I: Community Support Individual – To achieve and maintain rehabilitation, resiliency and recovery.
  CS-G: Community Support Group – To improve social skills in order to achieve and maintain rehabilitation, resiliency and recovery.
  CS-T: Community Support Team – To improve daily functioning in order to achieve and maintain rehabilitation, resiliency and recovery.
  DX: Psychiatric Diagnostic – To provide client with face-to-face contact with a psychiatrist to evaluate symptoms of the presenting problem(s)
        and develop treatment recommendations.
  MM: Medication Management – To improve functioning by medication treatment of symptoms of psychiatric illness.
  PMM: Psychotropic Medication Monitoring – Provide psychiatric medication monitoring to evaluate client’s compliance and medication
        effectiveness.
  PMT: Psychotropic Medication Training – To train the client or the client’s family and/or guardian to administer the client’s medication,
        monitor proper levels and dosage, and watch for side effects.
  PMA: Psychotropic Medication Administration – To prepare a client and the medication for administration, administering medications,
        and observing for possible adverse reactions.
  MHIO: Mental Health Intensive Outpatient – Intensive treatment to reduce or eliminate symptoms that have in the past or may in the near future
        lead to the need for psychiatric hospitalization.
  PSR-I: Psychosocial Rehabilitation-Individual – Intensive individual treatment to develop independent living, problem solving, and coping
        skills. (Adult Only Service)
  PSR-G: Psychosocial Rehabilitation-Group – Intensive group treatment to develop independent living, problem solving, and coping
        skills. (Adult Only Service)
  TLA: Case Management Transition Linkage and Aftercare – To facilitate an effective transition in living arrangement consistent with the
        client’s welfare and development.
  TBI: Traumatic Brain Injury Case Management – To provide support for development of compensatory strategies that reduce negative impact
        of cognitive, emotional and behavioral concerns associated with TBI and enhance self-management skills. Coordination of care services
        by providing advocacy, education, and linkage to needed resources and support.
  PA: Psychological Assessment – To conduct formal assessment of client’s functioning in the emotional, cognitive, behavioral, and
        personality domains resulting from target problem formation, diagnosis, and treatment recommendation.
  Chemical Screening – To monitor for the presence of substances and to measure progress in treatment.
  Substance Abuse Evaluation – To conduct a formal assessment of the client’s history of and/or current use of alcohol and/or drugs to
        determine the need for substance abuse treatment and education.
  VE: Vocational Engagement – To engage with the goal of helping the client to make a decision to seek employment or education.
  VA: Vocational Assessment – To assist the client in making positive employment related choices.
  JF: Job Finding Supports – To assist client with a goal of finding and procuring employment.
  JR: Job Retention Supports – To assist client with a goal of retaining employment.
  JL: Job Leaving/Termination Supports – To assist client with a goal of leaving employment in good standing.
  TLA-NF: Transition Linkage and Aftercare Nursing Facility – Effective transition in living arrangements.
  Medical Services Referral – Referring client to medical service provider to address any medical problem, assess for medical causation of
        mental illness, and/or determine the need for non-psychotropic medication/treatment to address an identified medical issue.
  Domestic Violence Services Referral - Referring client to domestic violence services provider to address any domestic violence problem(s)
        impacting client.
  Legal Services Referral - Referring client to legal service provider to address any legal problem(s) impacting client
  Dental Services Referral - Referring client to dental service provider to address any dental problem(s) impacting client.
  Nutritional Services Referral - Referring client to nutritional service provider to address any nutritional problem(s) impacting client’s
        psychological functioning and/or physical health.
  Other

ALCOHOL/DRUG ONLY PRELIMINARY TREATMENT PLAN/RECOMMENDED SERVICES

  EDUCATION                                        SOBRIETY SUPPORT GROUP                            SKILL BUILDING
  RECOVERY GROUP                                   INDIVIDUAL THERAPY                                ASAP GROUP
  MED MONITORING                                   FAMILY THERAPY                                    RANDOM DRUG SCREENS
  GROUP THERAPY                                    CASE MANAGEMENT                                   INTENSIVE OUTPATIENT GROUP
  CONSULTATION

JUSTIFICATION FOR ISSUES NOT ADDRESSED IN TREATMENT

ALL MENTAL HEALTH ISSUES PRESENT WILL BE ADDRESSED IN TREATMENT –                                   except the following (must explain):


16                                                                                                                       Rev 8/2010
Client Name                                                                                  Client ID #


REASONS:         Primary Issues Not Stable       Treated Elsewhere        Client refused      Other, specify:
DSM-IV DIAGNOSIS               (MUST BE 5 AXIS DIAGNOSIS)

AXIS I:
________.______                                                                                                        (PRIMARY DIAGNOSIS)
________.______
________.______
________.______
________.______
________.______
AXIS II:
   V71.09 - No Diagnosis
________.______                                                                                                        (PRIMARY DIAGNOSIS)

________.______
________.______
AXIS III:
   No Diagnosis on AXIS III
________.______
________.______
________.______
________.______
________.______
________.______
AXIS IV: Psychosocial and Environmental Problems
   NONE
   01 Problems with primary support group (specify)
   02 Problems related to the social environment (specify)
   03 Educational problems (specify)
   04 Occupational problems (specify)
   05 Housing problems (specify)
   06 Economic problems (specify)
   07 Problems with access to healthcare services (specify)
   08 Problems related to interaction with the legal system/crime (specify)
   09 Other psychosocial and other environmental problems (specify)
AXIS V:
   GAF                    C-GAS                       LOCUS                      CAFAS                          MULTNOMAH
                       Highest Level Of Functioning Over the Past Year Per Client Self-Report:                   GAF/C-GAS

LEVEL OF FUNCTIONING DATA
            Level of Functioning (Mark a 0 if the client functioning is not impaired or a 1 if functioning is impaired in each area below)
 Adult
  Social Group/School:_____        Employment:_____                            Financial:_____                            Community Living:_____
  Supportive Social:_____          Daily Living:_____                          Dangerous Behavior:_____                   Previous Impairment:_____
 Child and Adolescent
     Self care:_____     Community Functioning:_____            Social Relationships:_____         Family Relationships:_____       School:_____

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Client Name                                                                                        Client ID #
History of Illness/Disability (0 = Client does not meet treatment history criteria 1 = Client meets treatment history criteria)
 1 – Continuous Treatment           2 – Continuous Residential          3 – Multiple Residential         4- Outpatient            5 – Previous Treatment

RESPONSIBLE STAFF

   Primary:                                                                              Medical:

PROGRAM ASSIGNMENT

   01-- SASS I                                       02 – SASS II                              03 – SASS III
   05 – ICT                                          50 – TARGET OUTPATIENT                    52 – CHILD AND ADOLESCENT
   54 – PSR                                          57 – TRANSITION LINKAGE AFTERCARE         81 -- ORS – TBI
   82 – TRAUMATIC BRAIN INJURY                       83 – COMMUNITY OUTPATIENT                 90 – PROGRAM 90
   40—SUBSTANCE ABUSE YOUTH INTIATIVE                85 – SUBSTANCE ABUSE – ADULT (0.5)        84 – SUBSTANCE ABUSE - ASAP
   85 – SUBSTANCE ABUSE – ADULT (Level I)            86 – SUBSTANCE ABUSE INTENSIVE - ADULT (Level II)
   88 – SUBSTANCE ABUSE INTENSIVE - ADOLESCENT (Level II)

STAFF SIGNATURES AND CREDENTIALS
                                STAFF                                                                               DATE
                                                                         MHP
                                                                         QMHP
                                                                         LPHA
                                                                         MD/DO
                                                                         LPHA




18                                                                                                                                  Rev 8/2010

				
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