SHODAIR ADMISSION ASSESSMENT FORM. Pa tie nt Living Arrangement: Pa re nts Group Home Foste r Home JDC She lte r Othe r:

Transcription

1 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 SS#: Is youth emancipated, married or had a child? Yes No Name Adult(s) Legally Responsible: Father: Rights? Yes or No Hm# Cell# SSN Mother: Rights? Yes or No Hm# Cell# SSN Other #1: POA or Hm# Cell# SSN Other #2: POA or Hm# Cell# SSN DFS or Tribal: TIA TLC Full Custody Cell# Work# Assaultive behavior? No Yes Suicidalbehavior? No Yes Is patient an imminent danger to self or others? No Yes Reason for Admission: Mental Health Case Manager? No Yes Name: Phone# CSCT Organization/Therapist Name/Credentials/Ph#: Outpatient Therapist? No Yes Name/Credentials/Ph# Start Date: Last Appt. Frequency: Weekly Bi-Monthly Monthly Modality: Indiv. Family Group Previous Hospitalizations(Where/When): Past Psychiatric Diagnoses Identified: Current Meds/Doses: Meds Prescribed by: Phone # FamilyDoctor/Pediatrician Phone # Physical Health Problems? No Yes MRSA? Identify: Medication Allergies: Alcohol or Drug Use? Other Allergies: Prior Treatment Provider(s): Victim of Sexual Abuse? No Yes History of sexualized behaviors? No Yes Describe: History of Sexual Offenses? No Yes Prior Treatment Provider(s): Legal History? No Yes List: Probation Officer/Ph # Cognitive or Developmental Delays? No Yes Identify: School: 1

2 Medicaid or Insurance? List: Subscriber s Name/DOB: Reviewed by Dr. Approved for Admit? Recommendation: Acute Residential/Unit: NOT approved: Process # 2

3 Admission Status Psychosocial and Family Assessment Medical Records Label Date of admission Type of admission: Patient Ethnicity Voluntary Court Ordered Ethnicity: Tribe: Caucasian African American Hispanic/Latino Asian American/Alaskan Indian Hawaiian/Pacific Islander Other Not Applicable Assiniboine Blackfeet Cheyenne Crow Gros Ventre Kootenai Salish Sioux Shoshoni Other Adult(s) Legally Responsible for Patient Adult legally responsible for patient: Relationship to patient: Biological Mother Biological Father Step-Mother Adoptive Mother Adoptive Father Other Step-Father Date of Birth: SSN: Address: Home Phone: Cell Phone: Work Phone: Msg: Employer: Legal Custody Type: Occupation: Joint Full POA TIA TLC DPHHS Tribal DOC Guardian Ad Litum Have you provided legal documentation verifying custody? YES NO Other Adult Legally Responsible for patient: Relationship to patient: Biological Mother Biological Father Step-Mother Adoptive Mother Adoptive Father Other Step-Father Date of Birth: SSN: Address: Home Phone: Cell Phone: Work Phone: Msg: Employer: Occupation: 3

4 Other adult(s) involved with patient to be included in treatment: Relationship to patient: Home Phone: Cell Phone: Work Phone: Msg: Patient Siblings Please list all known siblings of the patient (include name, age, residence): Describe patient s relationship with each sibling: Patient Living Arrangement Living arrangement prior to hospitalization: Biological Parent Other Bio. Family Group Home Adoptive Parents Foster Care Juvenile Detention List individuals living with patient and indicate relationship to patient: How long has the patient lived in the current residence? Where else has the patient lived in the past 5 years? Does patient have access to firearms in the home? YES NO Are firearms kept locked and secured? YES NO Family History of Mental Illness Biological mother s history (check all that apply): Depression Bipolar PTSD Anxiety Substance Use Schizophrenia History of Suicide Attempts History of Completed Suicide History of Psych. Hospitalization Learning Disability None known Other Biological father s history (check all that apply): Depression Bipolar PTSD Anxiety Substance Use Schizophrenia History of Suicide Attempts History of Completed Suicide History of Psych. Hospitalization Learning Disability None known Other 4

5 Patient Developmental History Developmental History (check all that apply): Pregnancy Problems Postpartum Depression Speech Delays Any significant medical issues or treatment patient has had? YES NO At what age did the patient do each of the following: Walk? Talk? Toilet Train? Patient Behavioral Profile Prenatal Substance Use Temper Tantrums Disrupted Attachments Developmental Disability Genetic Abnormalities Sensory Difficulties No Concerns Pre-term Birth Regression Delay Motor Development Trouble Making Friends Delay toilet training Separation Anxiety Behavior Profile (check all that have EVER been present) Sexually Active Suicidal Ideation or behavioral issue Homicidal (check all that Ideation apply) History of Suicide Attempts Self Harm Physical Aggression Verbal Aggression Psychosis (visual or auditory) Irritability Depression Poor Hygiene Isolation Sleeping Less Sleeping More Hard to Wake Up Nightmares Loss of Appetite Excessive Appetite Poor Concentration Racing Thoughts Mood Swings Fire Setting Theft Running Away Lying Recent Losses Property Destruction Cruelty to Animals Anxiety School Refusal Bullying Others Being Bullied Conflicts w/peers Abnormal Toileting Habits Suspensions/Expulsions Difficulty w/authority Inappropriate Sexual Behavior Other Previous treatment for mental health List providers, dates of treatment, and length of stay: Previous treatment for mental health or behavioral issues (check all that apply) ER Visit Acute Hospitalization Residential Treatment PRTF Waiver Group Home Neurological Evaluation Psych Med Monitor Psych Testing Outpatient Ind. Therapy Partial Hos/Day Treatment Outpatient Family Therapy Group Therapy List providers, dates of treatment, and length of stay: Neglect and Abuse History Has the patient every experienced any of the following? (check all that apply) Explain: Physical Abuse Neglect None Physical Abuse to Another Sexual Abuse Verbal Abuse Verbal Abuse to Another Sexual Abuse to Another Witnessed Domestic Abuse Has Department of Family Services ever been involved? YES NO List dates, allegations, and findings: Any legal charges filed or in process due to allegations? YES NO 5

6 Legal History What is the current legal status of the patient s probation? Formal Informal None Probation Officer: Phone Number: Mark all that have EVER applied or CURRENTLY apply: Juvenile Detention Formal Probation Informal Probation Chemical Use History Mark ALL substances patient HAS used or IS using: Not Applicable Alcohol Marijuana Amphetamines Narcotics LSD PCP Methamphetamine Steroids Inhalants Nicotine Over the Counter Meds Tranquilizers/Sedatives Prescription Meds-Others Other(s) Mark ALL services patient has received for substance abuse Cocaine Ecstasy Previous treatment for chemical use issues: (check all that apply) Chemical Dependency Eval. Inpatient Outpatient Intensive Outpatient None Please list dates and length of stay of above services: Access to other(s) prescription or over the counter meds at home? YES NO Are medications locked and secure? YES NO School History School Name: Contact Person: Grade: CSCT: YES NO CSCT Organization Name: CSCT Therapist/Credentials: Phone: Mark all that apply: IEP 504 No Services Category: Conflicts with Peers/Adults? YES NO Previous Truancy Patterns: Preferred Learning Method: Auditory Visual Tactile Detentions/Suspensions/Expulsions: YES NO 6

7 Cultural and Spiritual Needs Spiritual Affiliation: YES NO Active in cultural or spiritual activities? YES NO Cultural/environmental factors impeding treatment? YES NO Special requests for spiritual or cultural needs: Leisure/Recreational Interests What are the patient s hobbies/interests and strengths? How many hours of TV, video games, or computer per week: Less than Greater than 25 Environmental Needs Placement option/stable housing after treatment: YES NO Access to adequate and reliable transportation: YES NO Is patient s neighborhood safe: YES NO Financial Needs Does the family receive public assistance: Is the family Medicaid eligible: YES NO YES NO Other financial needs: Community Resources What support systems does the family have access to? Church Mental Health Services DPHHS Probation Community Center After School Program Extended Family Advocacy Group Neighbors Rec Center None Other support systems for family: 7

8 Family Considerations What are the strengths and assets of the family? What is your hope for this hospitalization? Any other special needs of the family? Any additional information? Signature of Person Completing Form Date **Please fax completed form to Shodair Children s Hospital (406) or return in person upon admission 8