CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT. Name: DOB: SSN: Race: Sex: Marital Status: # of Children:
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1 CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT Date of Intake: Therapist: I. IDENTIFYING INFORMATION Name: DOB: SSN: Address: Race: Sex: Marital Status: # of Children: Living Situation: Legal Status: Referred By: II. PRESENTING PROBLEM III. PRIOR TREATMENT HISTORY DATES AGENCY NAME TYPE & LENGTH REASON FOR ADMISSION REASON FOR DISCHARGE Revised 04/11/02 1
2 IV. SUBSTANCE USE HISTORY A. CURRENT HISTORY: SUBSTANCE 1 ST USE LAST USE ROA FREQUENCY AMOUNT DURATION LONGEST ABSTINENCE B. CONSEQUENCES OF USE: YES NO Job troubles or job loss Problems with friends Blackouts Loss of control Previous attempts to cut down on drinking or drug use Impaired thought or memory processes Financial problems Spiritual impairment To relieve stress or frustration Increase or Decrease in tolerance Any history of withdrawal Physical problems caused by use of alcohol/drugs Any other addictions 2
3 V. PSYCHIATRIC HISTORY A. CURRENT: (Current symptoms, Diagnosis, Medications, Dosages, Prescribing Dr., Current suicidal or homicidal ideations) B. PAST: (Diagnoses, Medications, Suicide or Homicide attempts) C. MENTAL STATUS APPEARANCE: YES SOMEWHAT NO Unkempt / unclean/ poor personal hygiene Clothing disheveled/ unclean Inappropriate or unusual attire Comments regarding appearance: BEHAVIOR: YES SOMEWHAT NO Motor activity restless/fidgety Fast or rapid body movements Slowed or labored movements Atypical movements or tics Comments regarding behavior: 3
4 MOOD, AFFECT, AND NON-VERBAL EXPRESSION: YES SOMEWHAT NO Affect inappropriate to thought content Labile Blunted Limited range of affect Euphoric Angry/ hostile/ belligerent Fearful/ guarded Depressed/ sad Anxious Rigid/ tense Slumped Inappropriate/ bizarre Comments regarding mood: VERBAL EXPRESSION AND ENGAGEMENT: YES SOMEWHAT NO Loud Verbally over productive Barely audible Slow/ halted/ minimally productive Slurred/ stuttering or stammering Monopolizing/ domineering Distracted/ unfocused/ unorganized Excessively compliant or submissive Suspicious Uncooperative or resistive Comments regarding expression: PERCEPTION: YES SOMEWHAT NO Auditory hallucinations Visual hallucinations Olfactory hallucinations Tactile hallucinations Comments regarding perception: THOUGHT PROCESS AND CONTENT: YES SOMEWHAT NO Impaired consciousness Impaired concentration/ attention span Impaired abstract thinking Impaired calculation ability Impaired intelligence Irrational Oriented to person Oriented to place Oriented to time Obsessions Compulsions Phobias Comments regarding thought process: 4
5 MEMORY: YES SOMEWHAT NO Impaired immediate recall Impaired recent recall Impaired remote recall Comments regarding memory: VI. FAMILY HISTORY A. FAMILY OF ORIGIN: (Where raised, Parents, Siblings, Family history of alcohol or drug use and mental illness, Did they receive tx, History of Abuse: physical, emotional, sexual) B. CURRENT FAMILY/RELATIONSHIP STATUS: (Marriages, Current significant other, Children, Ages, Current relationship, Any alcohol or drug use or history of mental illness, Are they in treatment) 5
6 VII. LEGAL HISTORY (Current status, History of convictions w/ dates, Alcohol or drug related, Past hx of legal involvement, Involvement with CPS/Family Court) VIII. EMPLOYMENT HISTORY (Last job, #of jobs in last 5 years, Length of jobs, Types of jobs, Reasons for leaving, Terminations, Impact of alcohol/drug use and M.I., Desire to further vocational skills, Military?) IX. EDUCATIONAL HISTORY (Highest grade completed, Additional education/training, Impact of alcohol/drug use and M.I., Learning disabilities) 6
7 X. SPIRITUAL INFLUENCES AND BELIEFS (Childhood religion, Current religious and/or spiritual beliefs, Belief in higher power, Any cultural issues) XI. SOCIAL / RECREATIONAL ACTIVITIES (Self-help involvement, use of free time, friends, Activities which foster alcohol/drug use, Interference in activities due to alcohol/drug use and/or M.I.) XII. MEDICAL HISTORY (Primary Care Dr., Date of last physical, Any medical conditions/problems, Medications for medical problems, Allergies, Vitamins, # of E.R visits in the last 6 months, Nutrition, STD s) 7
8 XIII. INTEGRATED SUMMARY A. ASSETS LIABILITIES As Per Client: B. NARRATIVE (Please explain above in detail) As Per Therapist: 8
9 XIV. DIAGNOSTIC IMPRESSION AXIS I: AXIS II: AXIS III: AXIS IV: AXIS V: XV. INITIAL TREATMENT PLAN Group Therapy Psycho-educational Groups Medication Management Self-Help Meetings Referral for Primary Medical Dr. Referral for Physical Examination XVI. DISCHARGE CRITERIA / GOALS Therapist Date Clinical Director Date Medical Consultant Date 9
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PERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)
PERSONAL HISTORY PERSONAL INFORMATION: NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS_ PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP) AGE: DATE OF BIRTH: SOCIAL SECURITY #: RACE:
CHEMICAL DEPENDENCY EVALUATION INTERVIEW. A. Demographics
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SHODAIR ADMISSION ASSESSMENT FORM Date: Referring Party: Phone#: Pa tie nt Living Arrangement: Pa re nts Group Home Foste r Home JDC She lte r Othe r: Patient Name: Patient DOB: Age: Male Female Patient