Clinical Considerations for a Strength-Based Intake Assessment

Similar documents
CHILD / ADOLESCENT HISTORY

Initial Evaluation Template

ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT. Name: Date: Referred by:

CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT. Name: DOB: SSN: Race: Sex: Marital Status: # of Children:

Seasonal Affective Disorder and Other Mental Health Issues. Mental Health Issues and Juvenile Justice. Acronyms

BDS-2 QUICK SCORE SCHOOL VERION PROFILE SAMPLE

COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):

Psychiatric Residential Treatment Facility Referral

Child/ Adolescent Questionnaire

Name Age Relationship to patient

SAMPLE INITIAL EVALUATION TEMPLATE

Defining Mental Disorders. Judy Bass, MPH, PhD Johns Hopkins University

Hawthorne Veteran and Family Resource Center. Recuperative Care Program Referral Form. 250 N. Ash Street. Escondido, CA 92027

NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility Hwy. 190 Mandeville, Louisiana Phone: Fax:

Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:

AMITA Health Alexian Brothers Behavioral Health Hospital Child and Adolescent Questionnaire

Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )

INITIAL MENTAL HEALTH ASSESSMENT

PARENT QUESTIONNAIRE. Name of parent completing this form

Psychiatry CHILD, ADOLESCENT, AND FAMILY DATA MR #: Name: To be completed by parent or legal guardian.

3/9/2017. A module within the 8 hour Responding to Crisis Course. Our purpose

Family Background Questionnaire

Triage/Low Demand Shelter Screening Form

Patient Information Form

CSS Correctional Service System

ADHD Packet Introduction

HEADS UP ON MENTAL HEALTH CONCERNS IN CHILDREN WITH DEVELOPMENTAL DISABILITIES. CORNELIO G. BANAAG, JR. M.D. Psychiatrist

Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?

Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:

ADULT INTAKE FORM. Name

Externalizing Disorders

PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT

Section O, part 5d: Rating Scales

Attention Deficit and Disruptive Behavior Disorders

Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT

Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM

Client: Date of Birth: Date of Report: MENTAL STATUS EXAMINATION REPORT 1. Identifying Information

Swanson, Nolan and Pelham Teacher and Parent Rating Scale (Snap-IV)

Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT

Announcements. The final Aplia gauntlet: Final Exam is May 14, 3:30 pm Still more experiments going up daily! Enhanced Grade-query Tool+

Behavioral Health Psychiatric Residential Treatment Facility Referral Form

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

x S. Broadway, Suite 7 Pitman, NJ Intake Form

Substance Use Disorder Intake/Assessment Form

CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:

Psychiatric Nurse Practitioner Intake Form. General Information. 1. Name. 2. Date of Birth. 3. Age. 4. Gender. 5. Referred by

The Psychiatric Interview

MOOD (AFFECTIVE) DISORDERS and ANXIETY DISORDERS

Therapy Resources of Morris County, LLC

Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:

CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:

PRACTICE PARAMETERS FOR THE ASSESSMENT AND TREATMENT OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER

Warning Signs of Mental Illness in Children/Adolescents. Beth Confer, MA, LPC Director, Community Relations Clarity Child Guidance Center

ATTENTION DEFICIT HYPERACTIVITY DISORDER COMORBIDITIES 23/02/2011. Oppositional Defiant Disorder

Summary of presenting problem: Diagnosis: Axis I ... Axis II. Axis III. Axis IV. Axis V GAF = Services recommended: Therapy. Diagnostic assessment

BEHAVIORAL INTERVIEW Ken Tellerman M.D.

PERSONAL HISTORY QUESTIONNAIRE

Some newer, investigational approaches to treating refractory major depression are being used.

Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:

Demographic Information Form

Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating

Many people are confused about what Social Security benefits might be available to them. Here are answers to frequently asked questions.

Alcorn & Allison. clinical associates **C O N F I D E N T I A L**

Biographical History Form Child/Adolescent

Phone Screen. Beginning the Psychoeducational Process: The Intake. The Psychoeducational Process and Elements throughout Care

Serious Mental Illness (SMI) CRITERIA CHECKLIST

Scoring Instructions for the VADPRS:

AT RISK YOUTH ASSESSMENT YAR application/assessment must be reviewed with YAR coordinator prior to being filed

MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION

MINOR CLIENT HISTORY

LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information

New Service Provider Provider Type Provider Name Phone Ext

Typical or Troubled? By Cindy Ruich, Ed.D. Director of Student Services Marana Unified School District Office:(520)

Mental Health Awareness

*IN10 BIOPSYCHOSOCIAL ASSESSMENT*

PRTF Admission Application Packet CONSUMER INFORMATION GUARDIAN INFORMATION CONSUMER S PRIMARY REFERRAL SOURCE INFORMATION

HERTFORDSHIRE PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST. Referral Criteria for Specialist Tier 3 CAMHS

Adolescent Symptom Inventory-4 Parent Checklist 12 Years and Over Please return checklist to the office prior to your appointment

Child and Youth Background Information

CSS Correctional Service System

Adult Information Form Page 1

NICHQ Vanderbilt Assessment Scale PARENT Informant

ADHD FOLLOW-UP VISITS FOR STUDENTS IN MIDDLE SCHOOL OR HIGH SCHOOL

Time... Client Company:... Client Name/s:... Surname:...

SACRED HEART HOSPITAL 421 Chew Street Allentown, PA EAC REFERRAL PACKET REQUIREMENTS

Your journal: how can it help you?

Screening and Assessments for Trauma Adrian James, MS, NCC, LPC-S

BACKGROUND HISTORY QUESTIONNAIRE

Initial Substance Use Assessment

LOUISIANA MEDICAID PROGRAM ISSUED: 04/13/10 REPLACED: 03/01/93 CHAPTER 13: MENTAL HEALTH CLINICS SECTION13.1: SERVICES PAGE(S) 9 SERVICES

(Check if applicable)

Disruptive behaviour disorders Oppositional defiant disorder (ODD) / Conduct disorder (CD)

Case Study: Insights on the Incarcerated Adult ADHD Population

Demographic Information Form

Overview. Conduct Problems. Overview. Conduct Disorder. Dr. K. A. Korb, University of Jos 5/20/2013. Dr. K. A. Korb

Address: Spouse/Partner Name: Phone: Address:

COUPLE COUNSELING ASSESSMENT

Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC

Child and Adolescent Residential Services Referral Packet

Mood Disorders Workshop Dr Andrew Howie / Dr Tony Fernando Psychological Medicine Faculty of Medical and Health Sciences University of Auckland

Transcription:

Clinical Considerations for a Strength-Based Intake Assessment Initial Comments/ Assessment Summary 1. Client Demographics - Name: Age: Gender: Race: Note: Domain areas assess the identified child only - except Family/Relationships. Relevant information about family members should be included on page 4. 2. Referral Source - Child Welfare: Juvenile Justice: Education: Mental Health: Corrections: 3. Presenting Concerns (that lead to referral) and Strengths- Abuse: Alcohol/Drugs: Attention: Behavior: Danger (self/others): Psychiatric Symptoms (anxiety, depression, etc.): Disabilities/Challenges: Family Relationships: Legal: Peers: School:

2 Psycholog ical/emotional 1. Mental Status (see checklist: Supplement I) Appearance: Well-groomed, appropriate, inappropriate, poor hygiene, disheveled, Gang oriented clothing, alcohol-drug-tobacco oriented clothing, other Concentration: Good, limited, poor Orientation: Person self/others, place, purpose Psychomotor: WNL, agitated, hyperactive, slowed, tics, other Mood/Affect: Euthymic, appropriate to content, calm, cooperative, angry, anxious, Defensive, depressed, flat, labile, euphoric, suspicious, tense, Withdrawn, other Thought Content/Process: Logical, sequential, goal directed, blocking, delusions, grandiose, Hallucinations, paranoia, perseveration, rapid, slowed, spontaneous, Tangential, other Memory: Good, fair, poor Remote Recall: Good, fair, poor Estimated IQ: <Average, Average, >Average Impulse Control: Good, fair, poor Level of Consciousness: Alert, lethargic, other Judgment: Good, fair, poor Insight: Good, fair, poor 2. Treatment History Previous (with dates and provider names): Inpatient: Outpatient: Day Treatment: Residential: Group Home: Foster Care:

Counseling: 3 Current: Same as previous : 3. Diagnostic Information in support of diagnosis (see checklist: Supplement II)- Examples: ADHD (i.e. fidgets, distracted, difficulty following directions, unable to stay on task, trouble remaining seated, etc.) Major Depression (i.e. irritable mood, sleep/appetite disturbance, suicidal ideation, depressed mood, feelings of worthlessness, fatigue etc.) Bipolar Disorder (i.e. mood disturbance, manic behavior, hypo manic behavior, depressive symptoms, and associated symptoms related to mania and depression per DSM IV). Anxiety/PTSD (i.e. physical/somatic symptoms, worrisome, fearful, obsessive, compulsive, recurrent dreams/flashbacks of traumatic event, etc.) Oppositional Defiant Disorder (i.e. defies adult requests, temper, arguments, resentful, blames others, swearing, etc.) Conduct Disorder (i.e. illegal activity, physically cruel to animals, fire setting, destruction of property, etc.) 4. Global Assessment of Functioning Scale (CGAS for youth under 14) - Current Score: History: Description/Rationale (see scale): 5. Traumatic Events - Abuse: Deaths: Incarcerations: 6. Parental Concerns - Behavior: Emotions: Eating: Sleeping

Toileting: 4 Family/Relationships 1. Family Marital Status: Significant others (paramour) Separations Divorces Marriages Widow/Widower Orientation Siblings: Birth Order: Extended Family (biological, non-biological): Adoptions: Out-of-home placements: Other Caregivers: Custody/Guardianship Arrangements: Living Situations: Family Functioning (ability to parent, substance abuse, legal, etc.): Health: 2. Other Significant Relationships (past and present) Friends: Neighborhood: Community: 3. Sexual Activity Current: History: Pregnancy: STD: Treatment: Safety: 4. Traumatic Events: Deaths: Incarcerations: Abuse: Note: All relevant information about family members goes in this section.

5 5. Other Family Member Information (summarize life domain areas): Safety/Crisis 1. Risks and Supports What are the Strengths? Suicide: Thoughts Plans Attempts Supports available When and how? Homicide: Thoughts Plans Attempts Supports available When and how? Self-Mutilation: Thoughts Plans Attempts Supports available When and how? Aggressiveness: Verbal Physical Property Fire Cruelty to Animals Supports available When and how? Abuse: Emotional Verbal Physical Sexual Rape Domestic Violence Neglect Supports available When and how? Separation Issues and Neglect: Supports available Runaway: Purpose Destination Duration

Dangerousness/Safety How Returned Crisis Involvement (YES) 6 2. Current Crisis Plans and Plans for Safety - What are the Strengths? Family Solutions: System Supports: Leg al 1. Legal Involvement Probation (type): Parole: Incarceration: Runaway: DCS/CPS/CHINS: Illegal activities: Pending Charges: Substance Use 1. Substances Substances (list): Quantity: Frequency: Last Use: Method: Use Behaviors (where, with who, etc.): Triggers: 2. Current/Previous Treatment History - What are the Strengths? Inpatient: IOP:

Support groups (12step, AA, NA, etc.): 7 Educational/Vocational 1. Educational Status - School and School District: Special Education (category and type): Other Educational Services: Accommodations/Educational Supports: Current Educational Performance: IQ (if available from Psych/Ed Testing): 2. Vocational Status - Employment (current, history): Vocational Education or Services: Vocational Goals: Vocational Skills: Health/Medical 1. Health Conditions (vision, dental, physical, etc.) - Current: Previous: 2. Medical Events: Accidents: Surgeries: Emergency Procedures: 3. Treatment-

Primary Care Physician: Psychiatrist: Dentist: Optometrist: Other Health Professional: Hospitals Used: Medications and Prescriber: Last Appointment: 8 Home/Place to Live 1. Home Environment - Moves: Recent Changes: Placement: Family House/Apartment: Status and Impression: Family Satisfaction: 2. Neighborhood - Location: Family Satisfaction: Daily Living 1. Strengths - Skills (age appropriate): Abilities (age appropriate): Resources (age appropriate): Goals (age appropriate): 2. Needs - Skills (age appropriate): Abilities (age appropriate): Resources (age appropriate): Goals (age appropriate):

9 Cultural/Spiritual 1. Culture - Ethnicity: Traditions (holidays, rituals, etc.): 2. Religion - Affiliation: 3. Beliefs - Spiritual: Cultural: Values: 4. Community Involvement - Churches: Groups: Organizations: Financial 1. Medical Insurance - Type: Status: 2. Financial Supports/Income - Employment:

Child Support: System Support (AAP, SSI, etc.): 10 Social/Recreational 1. Youth Activities - Fun: Hobbies: 2. Family Activities - Fun: Hobbies: 3. Social Activities Home: Neighborhood: Community:

11 Supplement I : Mental Status Checklist Appearance: well groomed appropriate inappropriate poor hygiene disheveled gang oriented clothing alcohol, drug, or tobacco oriented clothing other Concentration: good limited poor Orientation: person place purpose time Psychomotor: WNL agitated hyperactive slowed tics other Mood/Affect: appropriate to content calm cooperative angry anxious suspicious defensive depressed flat labile euphoric suspicious tense withdrawn other Thought Content/Process: logical, sequential, goal directed blocking delusions grandiose hallucinations paranoia perseveration rapid slowed spontaneous tangential other Level of Consciousness: alert lethargic other Short-Term Memory: good fair poor Remote Recall: good fair poor Estimated IQ: below average average above average known IQ Assessor Impulse Control: good fair poor Judgment: good fair poor

12 Supplement II : Diagnostic Information Checklist ADHD Often fidgets/restless Difficulty remaining seated Easily distracted Difficulty awaiting turn in games or groups Often blurts out answers to questions Has difficulty following instructions from others Often shifts between incomplete activities Has difficulty playing quietly Often interrupts others Does not seem to listen Loses things Engages in physically dangerous activities Duration = months TRAUMA AND ANXIETY SYMPTOMS Sleep or Appetite disturbance: Worrisome: Fearful: Restless and/or Irritable Physical/somatic complaints (list): Obsessions (list): Compulsive behavior Recurrent recollection or dreams of traumatic event Flashbacks to traumatic event: Difficulty concentrating Intense psych stress at exposure to cues that symbolize traumatic event Duration = months Evidence of traumatic event OPPOSITIONAL DEFIANT DISORDER Often loses temper Argues with adults Defies or refuses adult requests or rules Deliberately does things to annoy people Often blames others for his/her mistakes Touchy or easily annoyed by others Angry or resentful Spiteful/vindictive Swears or uses obscene language Duration = months MAJOR DEPRESSION Depressed mood Irritable mood Lack of interest/pleasure in activities Appetite disturbance Sleep disturbance Psychomotor agitation/retardation Fatigue or loss of energy Feelings of worthlessness Excessive/inappropriate guilt Difficulty concentrating Indecision Recurrent thoughts of death Suicidal ideation Duration = months +CONDUCT DISORDER Aggressive to people/animals Destruction of property Theft or deceitfulness Serious violation of rules probation runaway truancy illegal activities Duration = months MENTAL RETARDATION: Mild: 50-55 to 70 Moderate: 35-40 to 50-55 Severe: 20-25 to 35-40 Profound: below 20-25 Borderline Intellectual Functioning: 71-84 Suspected/Unknown/Need Testing

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback