AMITA HEALTH ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL OUTPATIENT PSYCHOSOCIAL ASSESSMENT

Transcription

1 AMITA HEALTH ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL OUTPATIENT PSYCHOSOCIAL ASSESSMENT DATE: TIME: Name of Person Providing Information: (If not the patient, list name and relationship) Staff Reviewing Form: *I. COMMUNICATION Your preferred language. English Other Family s preferred language: English Other Do you need a foreign language interpreter? Yes No Do you need a sign language interpreter? Yes No Do you have any other communication barriers such as a visual, hearing or speech impairment? Yes No If yes, describe. *II. PRESENTING PROBLEM (Be as specific as possible) *How long has this been a problem? Days Weeks Months Years *III. EVENTS OR STRESSORS IN YOUR LIFE WHICH MAY BE RELATED TO YOUR CURRENT CONDITION. WHY ARE YOU SEEKING TREATMENT NOW? (Timeframe and Relevant History) Page 1 of 14

2 IV.SYMPTOM CHECKLIST: You may check more than one time-frame for each symptom. CURRENT LAST 2 WEEKS) RECENT LAST 6 MONTHS) PAST (OVER 6 MONTHS AGO) CURRENT LAST 2 WEEKS) Depressed Mood Psychological Abuse RECENT LAST 6 MONTHS) PAST (OVER 6 MONTHS AGO) Daily Irritability Physical Abuse Lack of Interest/Pleasure in Activities Sexual Abuse *Increase in Distressing Appetite Memories that Reoccur or Intrude *Loss of Appetite Recurrent Distressing Dreams Difficulty Sense of Reliving Sleeping/Poor Sleep Traumatic Events Decreased Need for Sleep Periods of Time You Can t Remember *Increased Need for *Intense Sleep Reactions to Certain Events *Restlessness or Inability to Concentrate *Avoidance of Thoughts/Feeling of Trauma *Difficulty Making *Detachment Decisions From Feelings, People and Places *Fatigue or Loss of *Delusions Energy (unreasonable thoughts/beliefs) Feelings of Worthlessness or Guilt *Feelings of *Difficulty Hopelessness Controlling Anger Hallucinations Recurrent Thoughts *Impulsivity of Death Racing Thoughts or *Stealing Ideas Distractibility Lying *Rapid Mood Refusal to Swings cooperate Shortness of Breath/Dizziness Defiant Behaviors If any of the above boxes are checked, please describe: *Staff, NOTE: If items containing a are checked, refer for further assessment. Page 2 of 14

3 IV. SYMPTOM CHECKLIST, cont.: CURRENT LAST 2 WEEKS) *Accelerated Heart Rate or Chest Pains *Trembling or Shaking *Sweating/Feeling Flushed RECENT LAST 6 MONTHS) PAST (OVER 6 MONTHS AGO) CURRENT LAST 2 WEEKS) RECENT LAST 6 MONTHS) PAST (OVER 6 MONTHS AGO) *Paranoia Nonresponsiveness Poor Grades *Choking Cruelty to Animals *Nausea/Abdominal Firesetting Distress *Feeling Unreal *Gambling *Numbness/Tingling *Bingeing/ Sensations Compulsive Overeating Fear of Dying or Going *Intentional Crazy Vomiting *Fear of *Diuretics/ Persons/Places/ Laxative Misuse Animals/Objects/ Situations *Intrusive thoughts *Excessive that produce anxiety Dieting *Rituals/Compulsive *Compulsive behaviors Exercising *Worry *Suicidal Ideation *Homebound *Suicidal (agoraphobia) Attempts *Forgetfulness *Suicidal Ideation with a Plan Difficulty Walking *Homicidal Ideation *ADL Changes (difficulty eating, dressing, caring for self) Somatic Complaints (physical complaints) *Homicidal Attempts *Homicidal Ideation with a Plan Agitation/Aggression *Assaultive Ideation Confusion *Actual Assaults Anxiety *Self-Injury/Self- Mutilation/Cutting If any of the above boxes are checked, please describe: *Staff, NOTE: If items containing a are checked, refer for further assessment. Page 3 of 14

4 IV. SYMPTOM CHECKLIST, cont.: On a scale of 1 5, please rate the following items over the past two weeks and provide an explanation of items that rank 3 or lower on space provided below: Poor Good Appetite: Energy Level: SLEEP: 1. Do you have difficulty falling asleep? Y N 2. Do you have difficulty staying asleep? Y N 3. Do you wake up too early in the morning? Y N 4. Do you feel sleepy or fatigued often during the day? Y N 5. Do you snore often? Y N Staff, NOTE: If patient endorsed any of the above symptoms, please complete additional sleep assessments. PARENT-TO-BE / PARENT ASSESSMENT A. Are you or your partner pregnant now or have you adopted a child? Yes No B. Have you had a baby within the past year? Yes No C. If yes, what was/is the date of delivery? D. If you are experiencing any of the following symptoms since your pregnancy or since your baby was born and they have persisted for 2 or more weeks, please check the following relevant boxes: Uncontrollable crying or persistent sadness Restlessness Anxiety, panic attacks Irritability and frustration Inability to sleep, despite fatigue and exhaustion Feelings of guilt, that you're a bad parent Loss of appetite Lack of interest in your child Severe problems with concentration Staff: *If yes to more than one of the above symptoms, notify PMD program to complete an assessment. *V. SUBSTANCE ABUSE (ALCOHOL AND DRUGS) HISTORY A. Current and Past Use B. Are you concerned about your use? Yes* No C. Has drug or alcohol use interfered with your work, school, family, or relationships? Yes* No (If yes, how?) Page 4 of 14

5 D. Has anyone ever told you they are concerned about your drug or alcohol use? Yes* No (If yes, explain) Staff, NOTE: If items containing a star (after the item is listed) are checked, refer to CD section of level of care screening and consider further assessment. *VI. FAMILY HISTORY OF MENTAL ILLNESS AND SUBSTANCE ABUSE: (Relationship to you, history of mental illness and/or substance abuse, and types of treatment (counseling, medication, programs, etc.) *VII. TREATMENT HISTORY: Please include psychiatric hospitalizations, residential programs, outpatient programs and therapy/medication management, from most recent to oldest. START DATE END DATE THERAPIST/PHYSICIAN OR PROGRAM CONTACT INFO. ( , phone or address) Not Helpful..Helpful Page 5 of 14

6 VIII. PERSONAL AND SOCIAL HISTORY: *A. Living situation (Include who you are living with, in what type of environment, and if this is a stable living arrangement) B. Military History C. Are there any financial concerns *D. Legal problems pending or in the past (probation, court dates, charges) (contact/phone number) *E. *F. Social Service Agencies involved (contact/phone number) DCFS involvement at present or in the past (contact/phone number) *G. History of sexual abuse, physical abuse or neglect as a victim or a perpetrator H. History of being bullied or bullying others I. Any exceptional events (trauma, illness, divorce, adoption, deaths, etc.) J. Social behaviors (include number of friends, regularity of social contact, hobbies, etc.) K. Family relationships (amount and quality of contact, describe relationships with immediate family members) Page 6 of 14

7 VIII. PERSONAL AND SOCIAL HISTORY, cont.: *L. Do you have a support network (either family or friends) that can help you outside the hospital with medication, appointments, etc.? 1. Do/did you have any current or past conflicts or problems related to sexuality or your sexual orientation? Yes No If yes, please explain. 2. Have you been sexually active in the past? Yes No 3. Are you currently sexually active? Yes No 4. If yes, do you use any type of protection: Yes No *M. Do you have any educational issues (learning disabilities or learning difficulties)? Yes No If yes, please describe. Do you think these may affect your treatment? Yes No If yes, how would you like us to address ii? N. How do you learn best? Visually Auditorily By Touch O. 1. Are there cultural and/or spiritual beliefs or values which may affect your treatment? Yes No If yes, how would you like us to address them? 2. Are you active in any religious denomination or faith? Yes No Describe your religious and spiritual orientation: 3. Do your spiritual beliefs cause you any conflicts or problems that might impact your treatment? Yes No If yes, please explain: P. Community resource/self-help groups you currently attend IX. EMPLOYMENT/SCHOOL STATUS: *A. What is your employment status (full-time, part-time, unemployed, retired, seasonal)? *B. Have you worked in the last 5 years? Yes No If not working, why not? Page 7 of 14

8 VIII. PERSONAL AND SOCIAL HISTORY, cont.: C. 1. Do you have a profession? Yes No 2. If yes (on C.1.), where do you work and what is the nature of your job? 3. If yes (on C.1.), do you supervise/manage others? IX. EMPLOYMENT/SCHOOL STATUS, cont: 4. If yes (on C.1.), do you have a professional license? Yes No 5. If yes (on C.1.), do you have high accountability in your profession? Yes No 6. Describe your life style : *D. *E. Answer if you are currently enrolled in school: Do you have any school difficulties? What are your current grades? School you attend: Grade: F. Are you receiving any vocational training? (Please describe) *G. The highest grade you have completed: H. Your attitude toward academic achievement and your preferences of areas of study and academic performance: X. SAFETY ASSESSMENT A. If you have been in a psychiatric hospital before, have you ever been physically restrained or secluded? Yes N B. Have friends or family every physically restrained you for any reason? Yes No C. Have the police or anyone else every physically restrained you? Yes No D. Do you have problems controlling your anger? Yes No E. Do you have problems controlling urges to hurt yourself? Yes No F. Do you have problems controlling urges to hurt others? Yes No G. Do you have access to lethal weapons at home? Yes No H. Do you have access to potentially lethal prescription medications at home? Yes No If you answered yes to one or more of the above questions, answer the following questions: Page 8 of 14

9 X. SAFETY ASSESSMENT, cont: 1. What makes you angry, frustrated or upset? 2. What are the early warning signs that you are getting angry, upset or frustrated? 3. What helps you calm down? Check all that apply. Time alone Reading Talking to someone to solve the problem Counting to 50 Physical exercise Medication Deep breathing exercises Thinking of the consequences Relaxation exercises Talking to myself in a positive way Drawing (take it easy, I can handle it) Writing in journal Comfort wrap with a blanket Other If the non-physical strategies above are not effective or viable, and you are in a rare emergency situation that puts you in danger of harming yourself or someone else, the staff and your attending physician could consider the use of restraints or seclusion. 4. Do you have a severe physical or medical condition or a history of sexual/physical abuse that would create a risk for you if restraints are required? Yes No If yes, describe. RESTRAINT SAFETY MEASURES [COMPLETED BY STAFF] If risk of restraints is determined: 1. Consult with attending physician or designee 2. Add Information to Master Treatment Plan 3. Alert Nursing Staff 4. Clearly Indicate Risk on Attendance Board and in Patient Chart XI. CURRENT LEISURE/RECREATION INVOLVEMENT (Check All That Apply) A. SOCIAL: Health Club Park District program Church Group Card Group Senior Citizens Group Other: None B. PHYSICAL Running/Walking Aerobics Swimming Golf Tennis Skiing Rollerblading Other None C. HOBBY: Music Arts/Crafts Reading Photography Computers Other None D. STRESS REDUCTION/COPING ACTIVITIES: Exercise Meditation Relaxation Techniques Other None What Prevents More Leisure Activities? Lack of Funds Physical/Emotional Difficulties Describe: No Interest Lack of Transportation Other Page 9 of 14

10 XII. PARENTS OF CHILDREN AND ADOLESCENTS: Rate the following behaviors of your child as of today. No Problem Severe Problem A. Violence/Aggression B. Depression/Irritability C. Unusual Thinking D. Impulsivity (acts before thinking) E. Inability to Focus/Concentrate F. Self-Destruction (substance abuse, self-injury, eating disorders, suicidal statements/gestures) G. Anxiety H. School Refusal I. School Performance If your child is having school difficulties, what are his/her current grades? *If parents are divorced, who does your child live with? Where is the other parent? Contact Info: Will he/she be involved in therapy here? *Who has legal custody? Staff, NOTE: Request and attach legal documents if needed to clarify visitation and sharing of information. Page 10 of 14

11 XIII. DEVELOPMENTAL MILESTONES: (Parents of child/adolescent patients only) Any problems or complications during Mother's Pregnancy During Delivery Immediately After Birth When did your child begin to: Early Average Late Sit without help Before 5 months 5-8 months After 8 months Crawl Before 6 months 6-9 months After 9 months Walk without help Before 10 months months After 14 months Speak first words Before 10 months months After 16 months Say basic phrases Before 15 months months After 24 months Stay dry all night Before 18 months months After 30 months Does your child have any of these problems Bedwetting Sight/hearing Learning Does your child have a problem Leaving you Leaving home Attending school If checked, please specify: ADOLESCENT MILESTONE QUESTIONS (Parents of adolescent patients only) Has your teen refused to attend school for more than three days in a row? Yes No Does your teen choose a healthy teen peer group? Yes No Does your teen follow your rules? Yes No Does your teen obey the law? Yes No Is your teen respectful to authority figures? Yes No Does your teen consider the feelings of others when making decisions? Yes No Does your teen logically think through the potential consequences of his/her Yes No behavior? Does your teen consider a variety of alternatives when solving problems? Yes No Do you believe your teen is successfully attaining adolescent milestones? Yes No If no, in what areas do they need help? Page 11 of 14

12 XIV. TREATMENT POTENTIAL (To be completed by patient and staff together) A. Describe your strengths B. Describe your limitations C. Patient s perceptions of the benefits/function of the problem behavior (to be completed by staff) D. Patient/family expectation of treatment (to be completed by therapist) E. Level of motivation and readiness for change *XV. DIAGNOSTIC PROBLEM AREAS (to be completed by therapist): AXIS I CURRENT GAF SCORE AXIS II HIGHEST GAF PAST YEAR AXIS III AXIS IV Additional assessments needed: Chemical Dependency Anxiety/OCD Nutrition Eating Disorder Risk of Harm Risk of Violence PPD Self-Injury Pain Autism Sleep Perinatal Mood Disorder Sleep Other: Preliminary discharge plan (Include community resources, name and phone number of outpatient therapist and psychiatrist, if known): Page 12 of 14

13 XVI. INTEGRATED ASSESSMENT SUMMARY (Include information from all available assessments at the time of admission i.e. psychiatric evaluation, previous records, physical health screen, etc. Indicate any barriers to learning. Provide a case formulation and preliminary plan for treatment): Therapist/Case Manager Date Time Physician Date Time Page 13 of 14

14 GENOGRAM ASSESSMENT Page 14 of 14