First Name *

Last Name *

Appointment Date *

Date of birth

Age

NOTE: PLEASE LEAVE NO AREAS

BLANK- USE UK for Unknown OR N/A FOR NOT APPLICABLE.

Date of Client Referral:

Source of Client Referral:

Licensed Person Completing Form:

Date of Intake Interview:

Date of Completion of Intake:

Person[s] Interviewed:

Relationship to client:

Address

Phone *

Emergency Contact:

Emergency Contact Telephone #:

Social Security Number

MA#

Resources Used to Complete the Initial Assessment/Screening: (Check all that apply)

Client
Referral
Family/Significant Other
Other

SECTION I - DEMOGRAPHICS/CHIEF COMPLAINT

Additional Demographics:

Additional Demographic Age:

Gender:

Gender Expression:

Sexual Orientation:

Ethnicity:

Religion:

Children/Child Adopted/Foster Care:

(Client is not adopted, in foster care, or over 18

N/A

Adoption date:

Who has legal custody of the child:

Relationship with child:

Does this individual also have physical custody?

YES

If no, who has physical custody and their contact information

Provide Contact Number

If yes, please provide the name and telephone number:

Chief Complaint: Immediate presenting concerns:

SECTION II -RISK ASSESSMENT

Brief Suicidal Risk Screening:

Level of Suicidality:

Suicidality Risk was assessed and deemed:

Plan/Method:

Availability of Means:

Intent/Preparation:

History of Attempts:

Family History of Suicide or Attempts:

Brief Violence Risk Screening:

Current Level of Aggression/Homicidality:

Aggression was assessed and deemed:

Current Threats of Aggression

Plan/Availability/Intent:

Current Property Destruction:

History of Aggression/Property Destruction

Are current problems a significant risk of danger to self or others:

YES

If yes, what is the crisis plan for safety?

Summarize Other Risk Taking Behaviors:

(Include behaviors as unprotected sex, using dirty needles, driving at excessive speeds, driving under the influence, etc.)

Psychiatric Evaluation Screening:

IF ANY ITEMS ARE CHECKED, DISCUSS IMMEDIATELY WITH LICENSED SUPERVISOR TO DETERMINE THE NEED FOR A PSYCHIATRIC EVALUATION AND / OR THE NEED FOR AN EMERGENCY PSYCHIATRIC EVALUATION.

Client reports suicidal, homicidal impulses or plan

Client is experiencing psychotic symptoms

Client is currently on or was on psychotropic medication within the previous six months but has discontinued it without the advice of his or her physician.

Mental Status Screening: (Check all that are appropriate and comment as necessary). Mental Status Screening is limited to information based on interaction with the client.

Appearance:

Neat

Disheveled

Eye Contact:

Good

Fleeting

Poor

Level of Cooperation:

Good

Moederate

Defiant/Resistant

Level of Alertness:

Fully

Drowsy/Tired

Stream of Thought:

Linear

Flight of ideas

Loose Associations

Eccentric/Odd thoughts

Orientation:

Person

Place

Time

Situation

Memory:

Intact

Impaired Short term

Impaired Long term

Insight:

Good

Fair

Poor

Judgment:

Good

Fair

Poor

Summarize History of Trauma (Abuse, Neglect, Violence, Sexual Assault):

(Assess trauma survivor concerns; spousal/partner abuse; abuse suffered as a child; physical, sexual, emotional or psychological abuse; PTSD, including from military service. Document whether the client was a victim, perpetrator, witness.)

Give details here:

Are their current indications of abuse, but none reported?

YES

If yes, please document your assessment, discussion, and plan

Family Medical/Psychiatric History:

List all somatic and psychiatric disorders and relation to client (Include substance abuse and mental illnesses):

Medications:

Summarize medication history, including efficacy of current and previously used medications, allergies, adverse reactions: (Please note all medications currently being taken by the client including over-the-counter, herbal, nutritional supplements, etc.)

YES

DOSAGE

Alcohol and Addictive Behavior Screening

[Present and History]:

NONE REPORTED

N/A

[CRAFFT 1 Substance Use Screening Instrument: Score 1 point for each answer of Yes]

Answering yes to >=2 questions is highly predictive of an alcohol/drug-related disorder. Refer for further assessment /treatment. [CRAFFT 1 Substance Use Screening Instrument: Score 1 point for each answer of Yes]

Answering yes to >=2 questions is highly predictive of an alcohol/drug-related disorder. Refer for further assessment /treatment.

Benzodiazepam:

valium

marijuana

other opiate

Other

E. Method of use

oral

smoking

snorting

injection

F. Money Spent:

daily

weekly

monthly

Last Use?

H. Substance Abuse Treatment and Hospitalizations:

C...Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? 0 Yes 0 No Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? 0 Yes 0 No Do you ever use alcohol/drugs while you are by yourself, ALONE? 0 Yes 0 No Do you ever FORGET things you did while using alcohol or drugs? 0 Yes 0 No Do your family or FRIENDS ever tell you that you should cut down on your drinking 0 Yes 0 No or drug use? Have you gotten into TROUBLE while you were using alcohol or drugs? 0 Yes 0 No

YES

R...Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

YES

A...Do you ever use alcohol/drugs while you are by yourself, ALONE?

YES

F...Do you ever FORGET things you did while using alcohol or drugs?

YES

F...Do your family or FRIENDS ever tell you that you should cut down on your drinking 0 Yes 0 No or drug use?

YES

T...Have you gotten into TROUBLE while you were using alcohol or drugs?

YES

1 Knight, John R. M.D. & Associates [Center for Adolescent Substance Abuse Research at Children's Hospital in Boston.] Research funded by several national sources, including the Robert Wood Johnson Foundation, NIAAA and SAMHSA

Psychiatric Treatment History and Response:

(treatment before current admission)

None Reported

N/A

Type of Treatment, Inpatient, outpatient, Start date, program and end date?

Summarize the diagnostic and treatment history as well as the response to previous treatment efforts listed above:

SECTION III- MEDICAL ISSUES/PHYSICAL FUNCTION

Medical/Physical Issues, including current health needs, co-occurring disabilities, disorders, and medical conditions:

Current or chronic medical/physical problems:

YES

If yes, please explain

Is client receiving treatment for any current or chronic medical/physical problem?

YES

UNKNOWN

If yes, please explain: If no, list reason and plan to address the issue:

Current pregnancy and prenatal care needs/issues, including legal and illegal drug use, whether prenatal care is being provided, whether the pregnancy impacts treatment, etc., or N/A:

Drug/Food/Environmental or Seasonal Allergy?

YES

UNKNOWN

Is the client experiencing any pain now or does the client have a recent history of pain? 0 Yes 0 No If yes; type of pain?

YES

TextHistory of Medical Issues/Procedures:

Using a 1 – 10 scale with 10 being the worst, how generally does the client experience/handle pain if there is report of current pain problem?

For clients over 3 years and under 10 years of age:

Ask the child to point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes his or her pain and record the appropriate number.

Dental Issues:

YES

Hearing Issues:

YES

Vision Issues:

YES

Sexual History:

Is the client sexually active?

YES

UNKNOWN

Is the sexual activity perceived to be a problem for the client?

YES

UNKNOWN

Comments:

Nutrition Screening:

Adequate nutrition/eating habits:

YES

UNKNOWN

Problems with overweight/obesity:

YES

Nutrition Risk Factors:

NONE

LOW

MODERATE

HIGH

Comment:

SECTION IV – FAMILY CIRCUMSTANCES/BIRTH AND DEVELOPMENTAL HISTORY

Current living environment: (include who lives in the home and relationships)

Client’s growing up and current environment: (include parent’s marital status and involvement in client’s life, siblings, children, marriages, and locations)

Current or past military involvement for client or family, if applicable

YES

UNKNOWN

Financial Challenges:

YES

Birth and Developmental History:

Adequate Prenatal care:

YES

Exposure to drugs and/or alcohol:

YES

Social Relationship/Attachments with family/friends/relatives:

YES

Social/Emotional Development:

Normal

Delayed

Sleeping

Normal

Abnormal

Toilet Training:

Normal

Delayed

Physical/Motor development

Normal

Delayed

Self-care skills:

Normal

Delayed

SECTION V - EDUCATIONAL/VOCATIONAL/LEGAL

Educational: (List schools client attended):

Current grade level:

Special Education/IEP Services

YES

Current program type:

General Education

Inclusion

Special Ed. or Self-Contained

Gifted or Honors

Is the client literate in English?

YES

Is the client literate in another language?

YES

Has the client failed two quarters in school?

YES

If yes to either or both questions refer for Educational Assessment unless the child has a current IEP or it is determined by the team to be clinically contraindicated. Comments:

Psychological Assessment:

YES

Support Systems:

Has the client repeated a grade, when he/she was not enrolled in a special education program?

YES

Bereavement Supports [Who can client talk to when troubled?]:

Need for, and availability of, social supports:

Activities/Leisure/Interests:

Strengths/Does well:

Educational Assessment:

YES

Vocational and Employment History and Current Status: (List employment history and last worked):

Legal Information: (Place any legal info here e.g. # of arrests, types of charges, dates, amount of time in jail.):

Does the client have a somatic and/or psychiatric advance directive(s)?

YES

Does the client or family have legal representation?

YES

Are there any legal or custody issues that could influence the client’s progress in care, treatment, and services?

YES

Unknown

Comments: Other Agency Involvement

SECTION VI - RELIGIOUS, SPIRITUAL, CULTURAL AND COMMUNITY SUPPORTS:

Summarize the Role Religion, Spirituality, and Cultural Plays in the Client’s Life: Religion/Denomination:

Is the client satisfied with the role that religion/spirituality/culture plays in his/her life

YES

Explain:

Client’s Psychological and Social Adjustment to Disabilities and/or Disorders:

SECTION VII - NON-ACADEMIC EDUCATION ASSESSMENT:

[Should any of the issues listed below be taken into consideration related to the non-academic learning

for the client or the family?]

FACTORS AFFECTING CLIENT’S ABILITY TO LEARN

Difficulty in understanding English?

YES

Other barrier to communication?

YES

Cultural or religious issues?

YES

SECTION VIII - BIO-PSYCHO-SOCIAL ASSESSMENT/TREATMENT PRIORITIES

(From all previously collected information)

Interpretive Summary: (Summarize from above including personal strengths, resources, personality traits, needs, liabilities, weaknesses, what the individual needs to recover, abilities, interests, skills, talents, competencies, what client believes will enhance her/his treatment, psychological and social adjustment to disabilities and/or disorders, complaints, suicide/homicide risk, substance abuse history, family history, developmental history, trauma and/or abuse, medical, educational, vocational, legal, spirituality, community supports, and non-academic education):

1. What is the client's/family's/significant other's perception of his/her needs and priorities in order of importance?

2. What is client’s expectation of therapy?

3. List any prioritized needs that are necessary for treatment that require referral to an outside provider:

4. List any needs that will not be addressed during this treatment and why:

Level of Care:

Is this the appropriate level of care?

Yes

No, client referred to a more/less intense level of care

Section VIII Diagnosis:

Section VIII Diagnosis: DSM-V Code

Referrals Needed for Further Assessment:

Physical Function:

Speech-Language:

YES

Occupational Therapy:

YES

Vision/Auditory:

YES

Dental:

YES

Somatic:

YES

Nutritional:

YES

Emotional/Educational/Psychosocial:

Psychiatric:

YES

Abuse/Neglect:

YES

Spiritual:

YES

Legal:

YES

Psychological/Cognitive:

YES

Educational:

YES

Notes *

Therapist Signature *

Clear

Supervisor Signature

Clear

Date *

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