1915(i) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT
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1 Assessment Date: DEMOGRAPHIC INFORMATION SLA Number: Recipient Name: (first, middle, last) Medicaid Number: Age: DOB: Ethnicity: Gender: Gender Expression: Marital Status: SSN: LOCUS: LONI: PRIMARY DIAGNOSIS: BEHAVIORAL HEALTH HISTORY I. CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health in recipient s own words/quoted.) II. PRESENTING PROBLEM/HISTORY OF PRESENT ILLNESS (Including recipient s reason for seeking services, precipitating factors, symptoms, behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and recipient expectation.) CURRENT BEHAVIORAL HEALTH PROVIDER NAME: PHONE NUMBER: III. PAST PSYCHIATRIC HISTORY (First onset of illness, past diagnostic and treatment history, medications, hospitalizations): Prior Outpatient Mental Health Treatment: No; Yes; Detail: Psychiatric Hospitalizations: No; Yes; Detail: Additional History/Comments: IV. SUBSTANCE ABUSE/DEPENDENCE (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.) Check any/all that apply in past 12 months: Alcohol Use; Illegal Drug Use; Injected Drug Use ; Tobacco Product Use; Prescription Drugs Abuse; Non-Prescription (OTC) abuse; Alcohol and/or Drug Overdose; Alcohol and/or Drug Withdrawal; Problems caused by gambling; Trouble stopping any substance; Caffeine Use; Substance Abuse Treatment History: None; Outpatient; Intensive Outpatient; Residential/Inpatient:; Detox; SUBSTANCE TYPE Include all use in last 30 days. AGE OF 1ST USE YEARS IN LIFETIME DAYS IN PAST 30 DAYS SINCE LAST USE AMOUNT ROUTE OF ADMINISTRATION PHYSICAL V. CURRENT MEDICAL CONDITIONS (Check all that apply) Pregnant Due date: Prenatal care: None Reported Congestive Heart Failure Asthma Seizure Cancer Underweight High Blood Pressure Stroke Emphysema Cirrhosis Chronic Pain Overweight Heart Disease Diabetes Epilepsy Digestive Problems Thyroid Disease Sexually Transmitted Dz. VI. CURRENT & PAST MEDICATIONS(Including non-psychotropic medications) Medication Name Dose Freq. Route Current COMMENTS (Reason Prescribed/Response, etc.) 1915(i) IA v.11 (5/21/2014) Page 1 of 5
2 VII. ALLERGIES No Reported Drug or Food Allergies; VIII. PRIMARY CARE PHYSICIAN NAME PHONE FAX IX. ADDITIONAL MEDICAL HISTORY (Diagnosis, Hospitalizations, Surgery, labs values, status of conditions, etc.) SOCIAL X. LEGAL STATUS Current Legal Status: None; Parole; Probation; Charges Pending; Past Legal Status: None; DWI; Prior Arrests; Court-Ordered Outpatient Treatment; AOT; Judicial; Incarcerations; Other; Other; Comment/Detail: Comment/Detail: Prior XI. FAMILY HISTORY (relationship status with relatives, family involvement in treatment, and living status of significant relatives): Custodial Status: Independent Adult; Biologic Father; Biologic Mother; Joint Biologic Parents; Gov t/judicial; Other: Contact Info: Name: Relation Phone # Adverse Circumstances in Family of Origin: N/A; Poverty; Criminal Behavioral; Mental Illness; Substance Use; Abuse; Neglect; Domestic Violence; Violence; Trauma; Divorce Family Stress: Low Stress; Mildly Stressful; Moderately Stressful; Highly Stressful; Extremely Stressful Family Supports: Highly Supportive; Supportive; Limited Support; Minimal Support; No Support Additional Comments: XII. TRAUMA HISTORY History of Trauma: None; Experienced; Witnessed; Abuse; Neglect; Violence; Sexual Assault; XIII. LIVING SITUATION (Current status and functioning) a. Primary Residence: Own Home; Apartment; Relative s Home; Group Home; Homeless; Living with friend/acquaintance How long at current residence? Level of time in community of residence? Family/Household Composition: Source of meals/food: Means of transportation: b. Needs -List what is needed to improve/maintain daily living situation (Ex. Transportation, ability to cook independently, housing subsidy, money in savings, caregiver resource assessment, etc.) c. Preferences - Include things recipient feels will enhance his/her living situation. d. Strengths -List assets, service options, and resources the person has to meet needs, including available housing options. (Ex. Knows area, applied for housing subsidy, can live with family member, unpaid care-giver resource available, etc.) 1915(i) IA v.11 (5/21/2014) Page 2 of 5
3 e. Abilities/Interests Include recipient reported skills, aptitudes, capabilities, talents & competencies that might assist in maintaining or improving living situation. XIV. LEARNING/WORKING AND FUNCTIONAL STATUS a. Employment/Education/Rehabilitation Status: Current source of income: Estimated Monthly Income Amount: Highest Grade or Completed/Degree: Military Status: Military Trauma: No; Yes; Difficulties with Reading/Writing: No; Yes; Estimated Literacy Level: Current Employment Status: Assistive Devices utilized/required: No; Yes; Prior Employment Status: b. Current Status & Functioning (Assess ability to fulfill responsibilities, interact with others, capacity self-care, missed activities, work or school due to health, etc.) Functional Status Impairment Rating: (From LOCUS Functional Status Evaluation Parameters.) Minimal; Mild; Moderate; Serious; Extreme. As Evidenced By: c. Needs - List what is needed to improve/maintain income, employment, education, vocational skills, etc. (Ex. Financial support, new skills, training, education, etc.) Problems with Basic Needs: Food; Shelter; Clothing; Funds; Healthcare; ADL s d. Preferences Include things recipient feels will enhance functional status with regard to income, employment, learning, literacy, etc. e. Strengths List assets, service options, skills & resources recipient has to meet needs. (Ex. Intelligent, motivated, supportive family, education, job experience, interest in furthering education or vocational status, etc.) f. Abilities/Interests - Include recipient reported skills, aptitudes, capabilities, talents & competencies that might assist in maintaining or improving functional status. XV. SOCIAL HISTORY AND COMMUNITY INTEGRATION a. Current status and functioning (Involvement in the community, social supports and activities, social barriers) Does Recipient feel supported by friends or family? ; Recreational Activities: Self-Help Activities: b. Needs - List what is needed to improve/maintain recreation, social functioning & community integration. (Ex. Meet new people, painting supplies, sports team, improve family relationships etc.) c. Preferences Include things recipient feels will enhance or stimulate recreational interests, social functioning & community integration. d. Strengths -List assets, service options & skills that may enhance socialization & community integration. (Ex. Friendly, athletic, independent, friend plays, paints, past history of compliance in treatment, signs of resilience despite past adversity, etc.) e. Abilities/Interests - Include recipient reported skills, aptitudes, talents & competencies that may help maintain or improve socialization & community functioning. 1915(i) IA v.11 (5/21/2014) Page 3 of 5
4 CURRENT STATUS XVI. MENTAL STATUS EXAMINATION (Circle or Check all that apply.) a. GENERAL APPEARANCE Healthy; As stated Age; Older Than Stated Age; Young-looking; Tattoos; Disheveled; Unkempt; Malodorous; Thin; Overweight; Obese; b. BEHAVIOR & PSYCHOMOTOR ACTIVITY Normal; Overactive; Hypoactive; Catatonia; Tremor; Tics; Combative; Abnormal Gait ; c. ATTITUDE Optimal; Constructive; Motivated; Obstructive; Adversarial; Inaccessible; Cooperative; Seductive; Defensive; Hostile; Guarded; Apathetic; Evasive; Other/Explain: d. SPEECH Normal; Spontaneous; Slow; Impoverished; Hesitant; Monotonous; Soft/Whispered; Mumbled; Rapid; Pressured; Verbose; Loud; Slurred; Impediment; e. MOOD: Dysphoric; Euthymic; Expansive; Irritable; Labile; Elevated; Euphoric; Ecstatic; Depressed; Grief/mourning; Alexithymic; Elated; Hypomanic; Manic; Anxious; Tense; f. AFFECT Appropriate; Inappropriate; Blunted; Restricted; Flat; Labile; Tearful; Intense; g. PERCEPTUAL DISTURBANCES None; Hallucinations: Auditory; Visual; Olfactory; Tactile; h. THOUGHT PROCESS Logical/Coherent; Incomprehensible; Incoherent; Flight of Ideas; Loose Associations; Tangential; Circumstantial; Rambling; Evasive; Racing Thoughts; Perseveration; Thought Blocking; Concrete; i. THOUGHT CONTENT Preoccupations; Obsessions; Compulsions; Phobias; Delusions; Thought Broadcasting; Thought Insertion; Thought Withdrawal; Ideas of Reference; Ideas of Influence; Delusions; j. SUICIDAL/HOMICIDAL IDEATION Suicidal Thoughts; Suicidal Attempts; Suicidal Intent; Suicidal Plans; History of Self-Injurious Behavior Homicidal Thoughts; Homicidal Attempts; Homicidal Intent; Homicidal Plans; k. SENSORIUM/COGNITION Alert; Lethargic; Somnolent; Stuporous; Oriented to: Person; Place; Time; Situation; Normal Concentration; Impaired Concentration; l. MEMORY Remote Memory: Normal; Impaired; Recent Memory: Normal; Impaired; Immediate Recall: Normal; Impaired m. INTELLECTUAL FUNCTIONING (Estimate) Above Avg.; Normal/Avg.; Borderline; Intellectual Disability Mild; Moderate; Severe n. JUDGEMENT Critical Judgment Intact; Impaired Judgment; o. INSIGHT True Emotional Insight; Intellectual Insight; Some Awareness of Illness/symptoms; Impaired Insight; Denial; p. IMPULSE CONTROL Able to Resist Impulses; Recent Impulsive Behavior; Impaired Impulse Control; Compulsions; XVII. RISK ASSESSMENT: Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use, criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc. a. Risk of Harm to Self: Prior Suicide Attempt; Stated Plan/Intent; Access to means (weapons, pills, etc.); Recent Loss; Presence of Behavioral Cues (isolation, giving away possessions, rapid mood swings, etc.); Family History of Suicide; Terminal Illness; Substance Abuse; Marked lack of support; Psychosis; Suicide of friend/acquaintance; b. Risk of Harm to Others: Prior acts of violence; If yes, when was most recent violent act? ; Destruction of property; Arrests for violence; Access to means (weapons); Substance use; Physically abused as child; Was physically abusive as a child; Harms animals; Fire setting; Angry mood/agitation; Prior hospitalizations for danger to others; Psychosis/command hallucinations; If yes, is there a history of acting on any commands to harm others? Yes No; c. Risk of Harm to Self or Others Rating: (From LOCUS Risk of Harm Evaluation Parameters.) Minimal; Low; Moderate; Serious; Extreme. As Evidenced By: d. Recipient Safety & Other Risk Factors: Feels unsafe in current living environment; Feels currently being harmed/hurt/abused/threatened by someone; Engages in dangerous sexual behavior; Past involvement with Child or Adult Protective Services; Relapse/decompensation triggers; e. Describe recipient s preferences and desires for addressing risk factors, including any Mental Health Advance Directives or plan of response to periods of decompensation/relapse (Ex. Resources recipient feels comfortable reaching out to for assistance in a crisis.): XVIII. CULTURAL AND LANGUAGE PREFERENCES (Language, Customs/Values/Preferences) a. Spiritual Beliefs/Preferences: b. Cultural Beliefs/Preferences: 1915(i) IA v.11 (5/21/2014) Page 4 of 5
5 XIX. 1915(i) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT PRINCIPAL DIAGNOSES (Provide principle behavioral and medical diagnoses) XX. INTERPRETATIVE SUMMARY Describe recipient s global preferences/hopes for recovery, recommended treatments/assessments, level of care, duration. Include clinical/central theme, co-occurring disabilities, environmental and personal supports/needs. IDENTIFIED NEEDS RECCOMMENDED SERVICES MH Services: ACT (21+) CPST (21+) PSR (21+)-Individual PSR (21+)-Group PSH Med Mgt Outpt Therapy (Ind) Outpt Therapy (Fam) Outpt Therapy (Group) SA Services: Residential Tx Halfway House IOP Ambulatory Detox Outpt Therapy (Ind) Outpt Therapy (Fam) Outpt Therapy (Group) Other (with explanation): SIGNATURE PRINTED NAME OF ASSESSOR SIGNATURE LMHP STATUS DATE NOTE: Once 1915(i) Independent Assessment, LOCUS & LONi Form is completed, please complete the Plan of Care document. 1915(i) IA v.11 (5/21/2014) Page 5 of 5
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