FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
SESSION INFORMATION
Client:
Staff:
Document Date:
Client Program:
Test-Client, FSA (17820) 1/1/1980
Marmaduke, Melisa (19162)
3/12/2013
OUTPATIENT (OP)
FSA ADULT INITIAL EVALUATION
Chief Complaints (in
client’s words):
History of presenting
problems and
contributing factors:
Areas of functioning
impacted by current
mental health or
physical conditions (self
care, language, social,
vocation, etc.):
Previous psychiatric
counseling and/or
treatment:
Substance use/abuse
history/treatment:
Community resources
currently being used:
Current living situation:
Medical History
History of significant
illness:
Current medical issues:
Current Medications
(including prescribing
physician, dose,
schedule):
History of medications:
Side effect history:
Sleeping or eating
problems:
Areas of stress:
Family History
Father (describe
relationship):
Mother (describe
relationship):
Siblings (describe
relationship):
Children(ages,
relationship, any special
needs or concerns):
Other significant
relationships:
Test-Client, FSA (17820)
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FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
Members of current
household:
Trauma History:
Educational History:
Occupational History (If
not applicable, please
indicate N/A):
Current occupation or
reason for leaving
workforce:
Support system (who
you rely on for
support):
Legal history and
status:
Religious affiliation:
Cultural affiliation:
Activities:
Emotional
Physical
Sexual
Case Formulation
Client’s desired
outcome for treatment:
Client’s view of his/her
strengths (that will
assist with achieving
this outcome and
potential barriers to
this outcome)
Coping skills or other
resources that have
been useful with past
or current challenges:
Client’s level of
motivation for change
(client can be asked to
scale level of
motivation on a 1-10
scale, or verbally
describe it; both client’s
perspective on
motivation and
therapist’s assessment
of motivation level
should be noted):
Test-Client, FSA (17820)
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FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
Treatment
recommendations
(modality: individual,
family, couples, or
group therapy;
psychiatric evaluation,
referrals for outside
services; and family
members or other
supports who will be
involved in treatment;
frequency of treatment;
projected length of
stay):
Current suicidal
ideation:
Suicidal Assessment:
Access to means:
History of suicidal
ideations/attempts
Homicidal ideation:
Homicidal assessment:
History of homicidal
ideation/behaviors:
Additional information,
if necessary, regarding
suicidal/homicidal
behaviors:
Active
Risk Assessment
Passive
Intent
Plan
None
Means
Yes
Yes
No ideation present
(client denies)
No plan, intent, but ideation present
No
No
Active
Intent
Passive
Plan
Means
Yes
None
No ideation present
(client denies)
No plan, intent, but ideation present
No
Bio-Psychosocial Assessment Identified Risk Factors/Strengths
Strength & Risk Factors
Identified Strengths (list
format may include:
support groups, people,
community activities,
Tx compliance, desire
to get better, other
items)
Identified Risks (list
form may include items
like: family Hx, self
destructive
thoughts/behaviors,
psychiatric symptoms,
antisocial behaviors,
anniversary dates,
other identified items):
Test-Client, FSA (17820)
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FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
Mental Status Exam v1.2
(Staff must complete client’s height and weight.)
Client’s height:
Client’s weight:
Appearance (Client’s
dress and hygiene):
Notable physical (note
additional physical
characteristics of client
here; include general
physical build, hair
color, tattoos/piercings,
etc.):
Eye Contact:
Body/Motor Behaviors
(tics, dyskinetic
movements, etc.)
Additional Comments
(related to Appearance,
Physical Features, Eye
Contact,
Body
Movement):
Speech:
Mood:
Affect:
Consumer Attitude:
Test-Client, FSA (17820)
Mental Status may only be completed by Master’s Degree or Higher
(exception for NJ Screeners)
Appropriate
Dirty
Neat
Bizarre
Other (describe)
Disheveled
Casual
Appropriate
Avoided
Within Normal Limits
Hesitant
Meaningful
Unsteady Gait
Other
Wringing Hands
Rocking
Rapid
Slow
Pressured
Hesitant
Loud
Soft/Low
Whispers
Accented
Poverty of Speech
Mumbled
Slurred
Stutters
Depressed
Frustrated
Dysphoric
Anhedonic
Blunted
Constricted
Flat
Cooperative
Apprehensive
Stressed
Agitated
Defensive
Numb
Anxious
Irritable
Angry
Hostile
Inappropriate
Labile
Evasive
Friendly
Guarded
Hostile
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Talkative
Monotonous
Responsive
Mute
Incoherent
Rate/Volume/Tone within
Normal Limits
Hostile
Elevated
Euphoric
Euthymic, Within Normal Range
Restricted
Tearful
Appropriate, Normal
Indifferent
Interested/Attentive
Playful
Seductive
Date Printed: 8/30/2015 11:06 AM
FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
Thought Content:
Thought Perception:
Additional Information
Related to Thought
Content and
Perception:
Orientation:
Judgment:
Memory:
Insight:
Provide Evidence to
Support Deficits in
Memory, Judgment,
and Insight
Sleep Descriptors:
Sleep, Additional
Information (quality
and hours of sleep, day
or night, nightmares,
changes in sleep
pattern)
Appetite Descriptors:
Appetite, Additional
Information (changes in
appetite, quality of
appetite, restriction or
binging behaviors):
Impulse Control:
Blocked
Compulsive
Confabulation
Confused
Delusional
Disorganized
Within Normal Limits
Auditory Hallucinations
Commanding
Grandiose
Obsessive
Organized
Paranoid
Preservative
Phobia
Racing
Rambling
Somatic
Tangential
Olfactory Hallucinations
Tactile Hallucinations
Visual Hallucinations
Suspected Hallucinations
Oriented in all 3 areas
Disoriented to Person
Critical
Automatic
Remote Impairment
Immediate Impairment
Intact or True Insight
Intellectual Insight
Disoriented to Place
Disoriented to Time
Impaired
Reality-Based
Recent Impairment
No Impairment
Impaired Insight
Denial of Disorder
Limited or No Insight
Wakes Frequently
Insomnia
Nightmares
Uses Medical Assistance
Constantly Eating
Binge/Purge Behaviors
Weight Loss
Weight Gain
No change
Uninterrupted/Feels
Rested in the Morning
Disrupted
Increased Appetite
Decreased Appetite
No Appetite
Appropriate Impulse
Control
Limited Control
Controlled in Certain
Environments
Poor Impulse Control
Other Observations (if
not captured above):
Test-Client, FSA (17820)
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FAMILY SERVICE ASSOCIATION – FSA
OUTPATIENT ADULT INITIAL EVALUATION
Client:
Date Diagnosed:
Diagnosis By:
External Diagnosis?
Description:
DSM Code-Description
Client DSM Diagnosis as of
Test-Client, FSA (17820) 1/1/1980
Diagnostic Formulation
AXIS II Personality Disorders and Mental Retardation
ICD Code – Description
Pri/Sec
Comments
AXIS IV: Psychosocial and Environmental Problems
Description
Severity
Validation Issues:
Electronic Signature:
Signature History
Action
Test-Client, FSA (17820)
Comments
AXIS V: Global Assessment of Functioning Scale
GAF Score not entered
Signatures
Error: Client program in Session Information is a required field. Please navigate to the first
module and update the Session Information.
Error: An Effective Date must be entered before his document can be signed.
Error: You must complete axis 1-IV of the DSM Diagnosis before this document can be signed.
The document cannot be signed until the errors above are resolved.
Date
Staff
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Date Printed: 8/30/2015 11:06 AM