Client #:____________
Provider:____________
Cornerstone Behavioral Healthcare
Initial Co-Occurring Assessment
Client Name: ____________________________________________ DOB: ____________ Age: ________
Provider: ____________________________________ Date of Service: ____________
Participants (in addition to client): _________________________________________________________
Time of Service: Start:_________________ End Time: ______________
Note: Italicized lists are pick lists in PIMSY.
Participants
o
o
o
o
o
Clinician
Client
DHHS Guardian
Parent(s)
Other (Please Explain)
Provider reviewed the following clinical documentation with client and obtained clients signature.
o
o
o
o
o
o
o
o
o
o
HIPAA Documents
Client’s Rights
Confidential Policy
Exception to confidentiality
Clinician Disclosure Statement (LCPC Only)
AC-OK
Consent/Disclosure
Release of Information
PCP Release of Information
Attendance Policy
Client provided legal documentation? (Custody, Probation, Etc.)
Yes, No, N/A (Picklist)
IDENTIFYING INFORMATION:
Gender: Female, Male, Other, Transgender
Living Arrangements: Live Alone, With Others (Please Explain), Other
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
Housing Adequate (yes or no), If no please explain
Employment (if employed for whom does the client work?)
What social services does the client utilize) Disability, Food Stamps, HEAP, Housing, MaineCare,
N/A, Other Services (Please Explain)
BARRIERS TO TREATMENT:
None, Physical, Family Objections, Finances, Insurance Restrictions, Legal Restrictions, Transportation,
Without Social Support, Work Schedule, Other Barriers
CURRENT MEDICATIONS: (Please use medications tab) {These medications will need to be entered into
the medications tab.}
CURRENT PROVIDERS:
1. PCP (if no PCP = unmet need)
2. Specialist
3. Therapists
4. Health Home Coordinator/Case Manager/Other
PSYCHIATRIC HISTORY:
Has the client had the following: Therapy, Medication Management, Suicide Attempts, SelfMutilation, Homicide, Assault, Other Treatment.
Was client hospitalized (if yes please explain when and where) Yes, Voluntary, Involuntary, Client Denies
being Hospitalized
CLIENT'S MEDICAL HISTORY:
1. Any medical/ physical problems (Le. diabetes, cancer, heart, asthma, allergies, thyroid etc.)
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
2. Surgical procedures (please describe)
3. Tests, Labs, Consultation for medical-substance abuse-mental health (please identify)
4. Dental provider (if yes provider name and date of last service)
5. Disability? (If yes, identify type)
6. Receiving disability compensation (if yes please describe)
CLIENT'S FAMILY OF ORIGIN MEDICAL HISTORY: (diabetes, cancer, heart, asthma, thyroid etc.)
1. Paternal: Identify family member(s) and health issue (If known, please describe treatment, meds or
response)
2. Maternal: Identify family member(s) and health issue (If known, please describe treatment, meds or
response)
CLIENT'S FAMILY OF ORIGIN MENTAL HEALTH HISTORY:
1. Paternal: Identify family member(s) and diagnoses (If known, please describe treatment, meds or
response)
2. Maternal: Identify family member(s) and diagnoses (If known, please describe treatment, meds or
response)
CLIENT'S DEVELOPMENTAL HISTORY:
1. Where is the client's place of birth?
2. The client was raised by: Adopted Parents, Biological Parents, Extended Family (please explain), Foster
Parents, Other (Please explain)
3. Parents married?
4. Number of moves client made in life time
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
5. Early Childhood Development
6. Client's siblings (Name(s) and Age(s))
7. What is the client's family contact: Frequent, Minimal, None
8. What is the client's marital status: Single never married, Engaged List months, Married for List years,
Divorced for List years, Separated for List years, Divorced in process List months, Live-in for List years, List
Prior marriages ( for self), List Prior marriages ( for partner)
9. What is the clients marital history (if applicable)
10. Does the client have children (names and ages)
11. Is client currently sexually active: Yes, Client Denies, N/A
12. Age of first sexual encounter
13. Was it consensual
14. What is client's sexual orientation: Bisexual, Heterosexual, Homosexual, Lesbian, Other
15. Libido: high level, moderate, No desire
16. Practice safe sex
SPIRITUAL HISTORY:
1. Does client have a spiritual belief (please explain)
2. What is the client's family spiritual belief
EDUCATIONAL HISTORY:
1. Highest grade completed and name of institution
2. Learning disabilities or special education (if yes please explain)
MILITARY SERVICE:
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
1. lf yes, what branch: Air Force, Army, Coast Guard, Marine Corps, Navy
2. Is the client on Active Duty
3. Type and date of discharge (if applicable): Entry Level Separation, Honorable, General, Other Than
Honorable, Clemency Discharge, Bad Conduct Discharge, Dishonorable
VOCATIONAL HISTORY:
1. At what age did the client start working
2. Is the client regularly employed
3. Client's current employer (name and length of employment)
4. Past employer(s) (Identify and Explain)
a. How long
b. Why did you leave
LEGAL HISTORY:
1. Was the client ever arrested: Yes, Client Denies, N/A
2. Was the client ever convicted, if yes what was the sentence: Yes, Client Denies, N/A
3. Current Legal Problems: Yes, Client Denies, N/A
TRAUMA & ABUSE HISTORY:
1. Any sexual abuse (Please describe: nature of relationship/duration/severity of abuse): Client Denies,
Offender, Victim, Witness
2. Any physical abuse (Please describe: nature of relationship/duration/severity of abuse): Client Denies,
Offender, Victim, Witness
3. Any emotional abuse (Please describe: nature of relationship/duration/severity of abuse): Client
Denies, Offender, Victim, Witness
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
4. Any neglect (Please describe: nature of relationship/duration/severity of abuse): Client Denies,
Offender, Victim, Witness
5. Has client ever been in an accident (if yes please explain): Yes, Client Denies, N/A
6. Has the client seen someone injured or die (if yes please explain): Yes, Client Denies, N/A
7. Has the client suffered a significant loss (if yes please explain) Yes, Client Denies, N/A
SUBSTANCE USE HISTORY:
1. Have you ever used or are using the following substances? (Please enter usage date on
"Substance Usage" tab)
Alcohol
Cocaine,crack
Marijuana,hashish(Cannabis)
Heroin
Non-prescription methadone
Other opiates and synthetics
PCP (phencyclidine)
Other hallucinogens (LSD, MDA,Psilocybin)
Methamphetamine (ice)
Other amphetamines (dexedrine,amphetamine,crank,speed)
Other stimulants (e.g. caffeine)
Benzodiazepine (valium, librium, tranxene)
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
Other tranquilizers (thorazine,haldol)
Barbituates (phenobarbital,secobarbital,pentobarbital)
Other sedatives and hypnotics
Inhalants (nitrites, freon, glue, turpentine, paint thinnner)
Over the counter drugs
Other
Tobacco
Client denies any usage
2. Has client ever received substance abuse treatment (Clinician: please reference Completion of
Treatment Guidelines COTG): Yes, Client Denies, N/A
a. For how long, and what are client's reactions or response to the treatment received
b. If applicable describe the client's experience with self-help groups (AA, NA, AI-non, etc)
c. Has the client been affected by the alcohol and drug use of family members and others around
client (please describe)
CLIENT’S MENTAL HEALTH STATUS:
1. Sleep, please document how many hours per night and how many times the client wakes per night:
Early Insomnia, Excessive, Middle Insomnia, Normal, Other
a. ls it hard to fall asleep?
b. Is it hard to get back to sleep?
2. Appetite, nutrition or dietary habits: None (duration please explain), 1 meal daily, 2 meals daily, 3
meals daily, Binging
3. Energy Level: High, Normal, Low
4. Suicidal/homicidal: Client Denies, Occasional Thoughts, Vague Plan, Serious Thoughts, Prior attempts,
Ideation, Clear Plan , Means to Carry it Out
5. Reliability (clinician's perception) Fair, Good, Poor
6. Appearance: If other please explain: Casual Dress, Neatly Groomed, Appropriate to Season, Stated
Age, Older, Younger, Disheveled, Unkempt, Other
7. Personal Hygiene: If other please explain: WNL, Well Groomed, Messy, Other
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
8. Behavior: WNL, Pleasant, Engaging, Co-operative, Guarded, Suspicious, Hostile, Hyperactive, Tremors,
Ties, Agitated, Restless, Other
9. Clothing: (If inappropriate describe if striking): Appropriate, Casual, Inappropriate (describe if striking)
10. Attitude: N/A, calm and cooperative, other (describe)
11. Eye Contact: (if changed during interview, please describe): Good, Intermittent, Little, None, Change
during interview (describe)
12. Speech: Normal Rate/Volume/Rhythm, Loud, Soft, Halting, Pressured
13. Psycho motor Activity: WNL, Slowed, Calm, Restless, Agitated
14. Interaction during interview: WNL, Cooperative, Submissive, Shy, Indifferent
15. Mood, temperament and emotional function: WNL, Angry, Anxious, Changeable, Excited
16. Affect: N/A, reactive and mood congruent, labile, tearful, blunted
17. Perceptual disturbances: None, Compulsions, Flashbacks, Grandiose reasoning, Hallucinations
18. Thought processes: N/A, goal-directed and logical, disorganized, other (describe)
19. Content of thought: WNL, Helplessness, Hopelessness, Illogical, Mood congruent, Poverty of
thoughts, Ruminations
20. Information and intelligence is appropriate for age and education
21. Orientation to: Person, Place, Time
a. Able to concentrate and follow instructions: (yes or no), If no please explain
22. Memory: (if other, please explain): WNL, Impaired, Short-Term, Long-Term, Other
23. Coordination: WNL, Fine motor skills, Awkward, Clumsy, Tics, Tremors
24. Judgment and Insight: WNL, Realistic, Age appropriate, Limited, Impaired, Impulsive, Other
25. Support Systems
a. Family
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
b. Friends
c. Community (includes professional-spiritual leaders)
26. Leisure Activities
a. Prior
b. Current
c. Other
WHAT BRINGS YOU HERE TODAY?
CRISIS & RISK ASSESSMENT
1. Is the client at risk to harm self or others?
2. Was the client given Crisis number?
3. Does the client need crisis intervention?
4. Is a Crisis Plan deemed necessary at this time?
5. Please rate your client's risk from 1-No risk to 10-high risk, please explain any rating 2 or above.
CLIENTS STRENGTH, CHALLENGES AND ASSESSMENT SUMMARY
1. Client's Strengths
2. Client's Challenges
3. Summary (Include info of client issue, and any past services, recommendations, and needs etc.)
1-6-2015- FHW
REV: 1/28/2015 - FHW
Client #:____________
Provider:____________
Diagnosis: The diagnosis will have already been entered in the diagnosis section of PIMSY, this is for
the benefit of the provider:
Axis 1: __________________________________________________________
Axis 2: __________________________________________________________
Axis 3: __________________________________________________________
Axis 4: __________________________________________________________
Axis 5: GAF (Current):____________________ GAF (Last Year):_________________
AC-OK:
Adult:
# of yes questions:___________
1-7: _______________ 8-13:_______________ 14-15: _______________
Adolescent: (Ages 10-20)
# of yes questions: _____________
1-6: _______________ 7-12:_________________ 13-15:_______________
Stages of change for Primary Diagnosis: Not Applicable, Pre-contemplation, Contemplation, Preparation,
Action, Maintenance, Termination
Client opted not to answer questions at this time (yes or no)
1-6-2015- FHW
REV: 1/28/2015 - FHW