Therapy Resources of Morris County, LLC
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- Ambrose Burns
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1 NEW CLIENT ASSESSMENT (CLINICIAN COMPLETES) Client NAME: DOB: DATE: 1. PRESENTING PROBLEM (s): Include reasons for seeking treatment now, source of information and reliability. Describe in behavioral terms and include symptoms. 2. HISTORY OF PRESENTING PROBLEM(s): Include onset of symptoms, contributing factors, history of and response to treatment. 3. FAMILY HISTORY: Include family history of psychiatric problems and or drug/alcohol use. 4. FAMILY S ROLE IN TREATMENT: Client s perception of family support/involvement. Include current and past involvement in treatment
2 5. HISTORY OF ABUSE: Denied Yes, please explain and include any history of physical, sexual, or emotional abuse either as recipient or perpetrator including relationship to client and age at which abuse occurred. 6. SEXUALITY: Include sexual orientation and other issues current or past that are contributing to current problems. 7. CULTURAL/SPIRITUAL/RELIGIOUS ISSUES: How does the client s cultural/spiritual background and beliefs contribute to his/her current condition and treatment? What are the cultural/spiritual strengths and impediments that will affect the client s treatment? 8. DEVELOPMENTAL ISSUES: Include problems in pregnancy and delivery, developmental milestones, and significant childhood illnesses.
3 9. RISK ASSESSMENT: identify and explain any risk factors that this client may have NO VIOLENCE RISK YES EXPLANATORY COMMENTS (current or past history) (Identify when, where, and how) Assaults on others Homicidal/assaultive ideation Destructive behavior (property) Fire Setting Legal system involvement Gang involvement Victim of abuse Injures animals Domestic violence Lack of conscience or remorse NO Violent/command hallucinations Paranoid delusions Stalking behavior Access to weapons Impulsivity with aggression SUICIDAL RISK (current or past history) Suicide attempt Suicidal gesture Suicide ideation Self-injurious behavior Specific plan Practice of Plan Access to means Family history of suicide YES EXPLANATORY COMMENTS (Identify when, where and how) NO OTHER RISKS YES EXPLANATORY COMMENTS (Identify when, where and how) Active substance abuse Active illegal behavior Eating disorder behavior Sexual behavior Chronic pain (describe) Explanation of Risk Assessment (indicating safety needs, situations under which the client may be a danger to self or others or present a risk of predatory behavior):
4 10. CIRCLE CLIENTS LEVEL OF DETERMINED RISK Low Risk Medium Risk High Risk Safety Plan including immediate needs and setting for treatment INTERVENTION (Include frequency) Responsible party PSYCHIATRIC/BEHAVIORAL CRISIS Referral made? Yes No DRUG/ALCOHOL CRISIS Referral made? Yes No Division of Child Protection and Permanency Referral made? Yes No 11. IDENTIFIED NON-BEHAVIORAL HEALTH PROBLEMS A) Identify the domains in which further assessment, education or treatment is needed. Any domains that are checked must be followed up on the problem summary list. Physical/Medical Nutritional Physical Functioning Pain HIV Testing Educational Issues Legal Issues Vocational Issues Developmental Issues Issues B) Identify problems that will not be addressed in treatment. State reason why they will not be addressed. Problem Reason
5 12. MENTAL STATUS EVALUATION: Check all that apply MOOD Euthymic Indifferent Fearful Angry Euphoric Labile Sad Anxious AFFECT Appropriate Inappropriate Labile Sad Angry Fearful Elated Tearful Blunted Flat ATTITUDE Cooperative Ambivelant Evasive Guarded/Suspicious Hostile Negative Uncooperative Negative THOUGHT PROCESS Normal Loose Circumstantial Perseveration Blocking Fragmented Flight of ideas THOUGHT CONTENT Normal Auditory Hallucinate Visual Hallucinate Delusions Obsessions JUDGMENT SELF PERCEPTION CONSCIOUSNESS MEMORY INSIGHT Good Fair Poor No impairment Depersonalization Derealization Describe: Alert Clouded Fluctuating Stuporous Normal Impaired Remote Recent Immediate Good Fair Absent Minimal MOTOR ACTIVITY ORIENTATION SPEECH APPEARANCE GENERAL BEHAVIOR Normal Agitated Slowed Tremor Tic Normal Disoriented to: Time Place Person Situation Spontaneous Verbose Pressured Under-productive Incoherent Appropriate Seductive Untidy Loud Cooperative Withdrawn Dramatic Restless Hostile PHOBIAS None Reported Present Specify: SLEEP WNL Increased Decreased Early Morning Awakening Frequent Awakening Nightmares Daytime Somnolence
6 13. BEHAVIORAL TRAITS - Please check if you are or in the past have experienced any of the following behaviors Shy Worries Moody Sad, cries Loner Expects Failure Selfish Lazy Avoids Adults Sexual Act Out Police Problems Tics or Twitch Easygoing Friendly Enthusiastic Confident Acts without Thinking Suicide gesture Suicide Attempt Angry/Defiant Quarrels Bullies Temper Tantrums Lies Frequently Destructive Steals Sets Fires Drug/Alcohol use Frequent headaches Stomachaches Messy Careless, Reckless Short Attention Span Frequent Daydreams Overactive Sloppy Hygiene Clumsy Psychiatric Problems Slow Moving Difficult Sleep Sleepwalking Bed Wetting Soiling Poor Appetite Weight Loss Overweight Often Ill Unusual Thinking Bizarre Behavior Blinking, Jerking Seizures Speech Problems Learning Problems Cooperative Generous Frequent Injuries 14. CLIENT S READINESS FOR TREATMENT: Include ability to recognize symptoms, medication adherence, and level of motivation to make changes. What is the client s level of knowledge/understanding of his/her condition? Very Knowledgeable Somewhat knowledgeable Limited knowledge Is the client motivated to make lifestyle changes? Yes No Questionable Treatment issues include: Anxiety Psychosis Slow learner Language Denial Anger Cultural/religious Physical Depression Indifference Cognitive deficit None : What are the client s interests and preferences in achieving valued community living, learning, working and social roles?
7 15. ADVANCE DIRECTIVES: Does the client have a Psychiatric Advance Directive: Yes No If yes, request a copy for the file and note where copies are kept. If a Psychiatric Advance Directive has been completed, is it registered on the state registry? Yes No Verified via: Internet Phone Findings: Website: or Phone: Does the client wish to create a Psychiatric Advance Directive? Yes No If yes, was referral information provided? Yes No 16. IMPEDIMENTS TO TREATMENT: Check all that apply Shows poor contact with reality Poor-fair response to medication in pas Denies psychiatric problem Poor-fair medication compliance in past Difficulty expressing needs Currently non-compliant with medications Little insight into illness/problem Rejects education about condition Does not express desire to change Minimal independence / ADLs Denies evident substance abuse Lacks support from family / significant other Does not experience support from spiritual or other group affiliations 17. FUNCTIONAL IMPACT: Strengths to support progress in Therapy: Strength 1: Strength 2: Strenth 3:
8 18. CLINICAL ANALYSIS: Evaluate relevant clinical information obtained in all sections of the Biopsychosocial Assessment. Include client s strengths and needs related to what symptoms require treatment, what psychological, social or biological factors precipitated the current episode of care; consider data from all assessments and axis IV
9 19. Conceptualized need for Treatment based on: Diagnosis and Severity, Symptoms and Severity, Dangerousness to Self or s, Disability in Social and Self-Care Psychiatric Physiological Personality Physical I II III DSM CODE/ ICD 10 CODE DESCRIPTION CATEGORY V CODE DESCRIPTION Relational Abuse/Neglect Educational/ Occupational Social Environment Crime or Interaction w/the Legal System Health Service Encounters Psychosocial Personal Environmental Circumstances Identified Risk Factors:
10 20. TREATMENT RECOMMENDATIONS List type of treatment, case management issues or other Collateral services issues that will be addressed or considered during treatment. RECOMMENDATIONS FOR LEVEL OF CARE: OPD Individual Therapy Specify: OPD Marital / Couples Therapy OPD Family Therapy Group Therapy Specify: Off Site Referral: 21. PRIORITY TREATMENT NEEDS: Treatment Objectives: Treatment Interventions: Discharge Criteria/Needs: Clinician/Intern Name (Print) Clinician/Intern Signature: Date: IF APPLICABLE: N/A Supervisors Name (Print) Supervisors Signature: Date:
11 CLIENT INTERVIEWS SUMMARY SHEET NAME: D.O.B. CASE NO. Staff Member Last Name Profession Intern Clinician Date of Interview Appt. ANK Can Person Seen Parent Client F M Class of Interview Treatment Ind Group Family Intake
12 CLINICAL CHART ORGANIZATIONAL AUDITING PROCESS CLIENT INITIALS: DOB: START DATE: END DATE: Use Check Mark for Compliance or N/A SECTION 1 SECTION 1 1 Month 3 Months 6 Months Year Initial Inquiry or Walk In Questionnaire Emergency Contact Information NOTES: LOCI Placement Outcomes Measurement (Monthly Reviews) Psychiatric Evaluations (Monthly Reviews) Collaborative Summaries Closing Summary/Discharge Report Client Interview Summary Sheet SECTION 2 Consent To Treat/Electronic Communications SECTION 2 Standard Rates Client Financial Agreement/Insurance Authorization Credit Card Processing Form Release of Information Counselor Intern Disclosure Form Chart Organization Form SECTION 3 Individual Service Plan SECTION 3 Genogram/Family Involvement (Monthly Reviews) Homework Assignments Cultural Identifiers SECTION 4 Progress Notes Section SECTION 4 Individual/Cult/Spir/Ethnic Family Systemic/Involvement Group/Multi-Family Case Management SECTION 5 Health/Nutrition Screen SECTION 5 Lab Reports and Studies Toxicology Reports SECTION 6 Court Orders, Subpoenas, etc. SECTION 6 Letters and Correspondence s
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