CMBHS Clinical Management of Behavioral Health Services

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Client: CMBHS Clinical Management of Behavioral Health Services Case Management AST022 Assessment Information Assessment Number Assessment Date Assessment Type Contact Type Assessment Site Referred By Client Issue Presenting Problem In the Past 30 days What Substances you have been using? Route of Administration Frequency of Use Age of first use? Primary Secondary Tertiary What substances do you seek? How many days have you used? How many days have you not used? Literacy, Language or Auditory challenges?

Other Current Service Providers Provider Type Provider Name Phone Ext Staff Info Interviewer Primary Counselor

General Education Information What is the highest grade in school you completed? Did you ever need extra help in school? If, select English as a Second Language Mobility Aid Special Education Behavioral Health Services Speech Therapy Alternative School In the last 12 months have you been bullied? Are you currently in school? Would you like assistance with your educational status? Would you like assistance with obtaining a GED? N/A Employment Are you currently employed What is your employment status? Reason for not in Labor force? Would you like assistance with your employment status? What is your primary source of income? When you work, type of work do you do? Maternal Alcohol Use To your knowledge, did your mother ever drink alcohol that caused problems for her or others around her? Did your mother drink alcohol when you were young? Did your mother drink alcohol while she was pregnant with you? Has anyone ever said anything to you about your mother s drinking during her pregnancy with you? Unknown Unknown Unknown Unknown Current Trauma Do you currently feel safe where you live? Do you currently feel safe with the people in your life?

Family Social tab Current Social Status What is your living situation? Dependent Independent Homeless If dependent: Dependent Family Home Supported Housing Assisted Living Nursing Home Hospital Correctional Facility Other In the last 30 days have you been released from a secured environment such as residential substance use disorder treatment program jail or prison? If yes, in the year before you entered the controlled environment did you use opioids? Marital status Divorced Never Married w married Separated Widowed How many children do you have under the age of 18? Child Name Age Gender Legal Custody List your Children 1 2 3 4 Are you currently working on Reunification? Would you like assistance with Reunification?

Physical Health Current Information Do you currently have a chronic medical condition? If Y es Please explain Are you currently taking any prescribed medications for medical reasons? If what are they? Are you enrolled in Medication Assisted Treatment? Are you prescribed any of the following? Naloxone Suboxone Methadone Subutex Buprenorphine Vivitrol If any were marked, have you recently stopped prescription use of Vivitrol (naltrexone), methadone, or buprenorphine (Suboxone, Subutex)? Have you experienced a non fatal overdose? If yes, have you ever been administered naloxone or Narcan? In the past 30 days, how many days have you been hospitalized? Have you given birth in the last 18 months? If yes, have you used opioids in the past 3 years? Are you currently pregnant? Do you think you could be pregnant? Unknown Are you using tobacco? N/A Would you like assistance to cut back or quit? Would you like assistance with Your Physical health Obtaining Medical Insurance Your Dental Health Your Vision care Obtaining Medical Prescription HIV Medical Care STD/STI Services HCV Services Prenatal Care Reproductive/Sexual Health

Mental Health Historical Information Other than a problem with substance use, have you been told you have mental health difficulties or disorders? If what were you told? Have you ever tried to commit suicide? Current Information Are you currently seeing a Licensed Professional of the Healing Arts for any mental health condition or problem? If what are you being treated for? If, are you taking any prescription medications? If what are they? Are you currently having thoughts of killing yourself? Would you like assistance with your mental health?

Do you frequently have difficulties with any of the following: Concentrating and paying attention? Understanding what adults are telling you? Remembering things? Following rules and instructions? Getting along with others without arguing or fighting? Being on time? Keeping enough money to last you throughout the month? Doing things that later you wish you hadn t done? Getting really upset at little things or what people have told are little? Forgetting or missing appointments? Being surprised when you are in trouble? Have you ever tried to commit suicide? Have you wished you were dead or wished you could go to sleep and not wake up?

High Risk behaviors Have you ever Injected drugs? Shared injecting equipment? Shared equipment for snorting drugs? Had unprotected sex without condoms or latex barriers? Had unprotected sex with someone who injects drugs? Engaged in self injurious behaviors? Do you have tattoos or piercings? Have you had a persistent couch (longer than three months) and not visited a doctor? Have you been tested (screened for TB) within the past year? Briefly describe current risk behaviors: Substance Use Age at first use of any substance? 6 7 8 9 10 11 12 13 14 15 16 17 18 Have you ever sought Substance Use Treatment before today? If yes what treatment have you received? Please supply the number of treatment episodes the client received for each treatment service Number of Episodes Treatment Services Received Sum of number of prior treatment episodes

Recommendation Client selected support needs Education Your Dental Health Employment Obtaining Medical Insurance Obtaining Medical Prescription Trauma Sober Activity GED Reunification Services Recovery Coach Your Vision Care Mental Social Living Environment Living Situation Social Welfare HIV Medical Care Family Support Support Group Health Programs Veterans Affairs STD/STI Services Housing Environment, Paying for Housing Food Assistance Legal HCV Services Tobacco Prenatal Care Financial Assistance Programs Children s Services and Needs Your Physical Health Reproductive/ Sexual Health Child Welfare System Community Support Transportation Assistance Help Desk: 1 866 806 7806 2017 Clinical Management for Behavioral Health Services (CMBHS), Texas Health and Human Services Commission. All rights reserved.

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