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ADVOCATES FOR CONSUMER

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					Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544




                   ACCESS BEHAVIORAL ASSISTANCE


                                   ADMISSION ASSESSMENT

Name _______________________ DOB _____________ ID # ___________
Unique ID ___________________

Date Of Admission ___________________

Evaluation Date ___________________

Identifying Information:

Age: ___________

Gender: _______________

Phone Number __________________________________

Social Security Number ____________________________

Marital Status ___________________________________

Race/Ethnicity ____________________________________

Insurance: _______________________________________
          _______________________________________

Parent/Guardian Information
______________________________________________________________________________
______________________________________________________________________________

Referral Source _______________________________________________________________

Current Location: (address/lives with relative, etc.)
______________________________________________________________________________
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                                          1                    Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544

Work/Financial Information:
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Reason for Admission:

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History of Present Problem:
______________________________________________________________________________
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Admitting Diagnosis: (please list where this information was retrieved, if Dr. was consulted for this section
please have him sign underneath)

Axix I : __________________________
        __________________________
Axis II:___________________________
        ___________________________
Axis III:__________________________
         __________________________
Axis IV:__________________________
        ___________________________
Axis V:___________________________




Mental Status Exam-Please (circle all that apply make comments)


                                                    2                                     Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544


Appearance: Clean Neat well Groomed Disheveled Filthy Dirty Inappropriate Attire
Other (describe) ______________

Comments:_____________________________________________________________________
____________________________________________________________________________

Orientation: No Problems, Problems with…Person Date Day Time Place Year Season
Month
Comments:_____________________________________________________________________
______________________________________________________________________________

Behavior: Appropriate Disorganized Out of Control
Comments:_____________________________________________________________________

Speech: Articulation ( Clear, Mumbled, Slurred) Volume ( Loud, Soft, Normal, Whisper)
Rate ( Slow, Hesitant, Rapid, Normal)   Rambling Flight of Ideas
Comments:_____________________________________________________________________
______________________________________________________________________________

Difficulties with Memory:
Short term memory intact? Yes  No
Long term memory intact? Yes    No
Comments:_____________________________________________________________________
______________________________________________________________________________

Difficulties with attention/concentration
Ability to concentrate on task? Yes     No
Comments:_____________________________________________________________________
______________________________________________________________________________

Difficulties with cognitive function/intellect:
Appropriate for age : Yes No                    Impaired: Yes  No
Comments:_____________________________________________________________________
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Difficulties with Insight/Judgment: Normal Impaired Poor Lacking
Comments:_____________________________________________________________________
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Difficulties with Motor: Unremarkable Coordinated Uncoordinated Ambulatory
Non-Ambulatory Abnormal Movements
Comments:_____________________________________________________________________
______________________________________________________________________________




Difficulties with Alertness: Alert Drowsy Stupor Comatose Other__________________



                                       3                            Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544

Comments:_____________________________________________________________________
______________________________________________________________________________

Affect: (what consumer looks like) Normal Happy Calm Depressed Anxious Sad Crying
Agitated Manic Flat Screaming Tremulous Perspiring
Comments:_____________________________________________________________________
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Mood: (consumer reports) Tranquil Depressed Euthymic (positive mood)
Dysthymic (mildly depressed) Euphoric
Is this affect congruent with the mood? Yes No
Comments:_____________________________________________________________________
______________________________________________________________________________

Thought Process and Content: (list all that apply) Unremarkable Death Wishes Depressive
Thoughts Obsessions Ruminations Phobias Overvalued Ideas
Hallucinations: Rational Irrational TYPE: Audio Visual Tactile Olfactory
Suicidal ideation present: Yes No       Plan Yes No
Homicidal Ideation Present Yes No Plan Yes No
Comments:_____________________________________________________________________
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Additional comments/topics client wishes to discuss:
______________________________________________________________________________
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                                       4                             Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544


Date of last physical exam:_______________________________________________________

Current medical illness/problems and medications prescribed for medical or psychiatric
condition:
______________________________________________________________________________
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Medical History: (please include history of serious/traumatic illness, surgery, other)
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Medication Allergies:
______________________________________________________________________________
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Primary Care Physician: (Name, Address, and Phone Number)
________________________________________________________________________________________________
________________________________________________________________________________________________

SocialHistory:
______________________________________________________________________________
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Educational History:
______________________________________________________________________________
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Family History:
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                                            5                              Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544




Siblings:
______________________________________________________________________________
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Special Needs:
______________________________________________________________________________
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Treatment History (any hospitalizations inpatient/outpatient treatment facilities, etc):
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Alcohol and Drug History:
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Criminal History: Have you ever been convicted of a felony or misdemeanor? Yes___ No___
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Nutritional History:
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Additional Information:


                                        6                            Revised 6/30/2009
Access Behavioral Assistance
1703 Country Club Road suite 304
Jacksonville, NC 28544

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Signature of Staff (QP) and date




Signature of Client and date




                                   7                         Revised 6/30/2009