BEHAVIORAL ASSESSMENT
IDENTIFYING INFORMATION
NAME:
DATE:
DOB:
Gender:
Age:
Ethnic Background:
Counselor:
Lang:
Home Lang:
SEXUAL ORIENTATION/CULTURAL/FAMILY/SPIRITUAL ISSUES
Grade:
Glasses:
Y
N
( ☐None reported)
GENOGRAM
COLLATERAL CONTACTS
CSW:
THERAPIST:
PSYCHIATRIST:
SCHOOL HISTORY
ELEMENTARY:
JR
HIGH/INTERMED:
HIGH SCHOOL:
Prior Psychoeducational Assessments? ☐NO ☐YES:_____________________________________________________________________
DISABILITY:
SE INCEPTION:
DISCIPLINE HX:
RETENTION:
☐Office Referrals ☐Suspensions ☐Expulsions
Details:
1
PSYCHIATRIC HISTORY
(☐None reported)
History of Mental Illness in Family:
Previous INPT and OUTPT MENTAL HEALTH TX (include dates, providers, diagnosis, results):
☐No previous inpt tx
☐No previous outpt tx
Current and Past Medications (psychotropic & other, including over-the-counter) (include dosage if known):
Past: (☐None)
Current:
(☐None)
Appearance/Behavior:
Speech:
☐Organized
☐Coherent
Thought Process:
☐Organized
☐Coherent
☐Tangential
Mood:
☐Euthymic
☐Elevated
☐Anxious ☐Dysphoric
☐Appropriate
☐Inappropriate
☐Guarded ☐Irritable
☐WNL
☐Decreased
Affect:
☐Flat
Energy:
Sleep: (☐No problems reported)
☐Night Terrors
Appetite: (☐No problems reported)
☐Initial Insomnia
Insight:
Judgment:
☐Good
☐Good
☐Flight of Ideas
☐Depressed
☐Blunted
☐Labile
☐Restricted
☐Increased
☐Broken Sleep
☐Insomnia
☐Nightmares
☐Increase in Appetite ☐Decrease in Appetite ☐Purging
Delusions/Thought Content: ☐Denied ☐Paranoid delusions present
Hallucinations/Perceptions:
☐Thought-blocking
☐Denied
☐Grandiose delusions present
☐Auditory hallucinations present ☐Visual hallucinations present
☐Average ☐Poor in general
☐Average ☐Poor in general
☐Issue-specific:
☐Issue-specific:
Three Wishes:
Best/Worst:
Strengths/Weakness:
Other’s views of strengths/weaknesses
Social (best/close friends; girl/boyfriends):
Interests:
I get really mad when:
I love:
I hate:
Scenario: SPILT MILK:
Scenario: BIRD IN HAND:
Scenario: SHALLOW STREAM:
AFTER-SCHOOL SCHED:
2
☐Hx
☐Hx
MEDICAL HISTORY
Current Health Problems: (☐
None reported)
Head Injuries, Unconsciousness, Seizures: (☐No history)
☐History of head injuries, unconsciousness, seizures
SUBSTANCE PROBLEMS (describe use)
Nicotine
(☐
n/a)
☐Exper. Hx
☐Sig. Hx
☐Current
Alcohol
(☐
n/a)
☐Exper. Hx
☐Sig. Hx
☐Current
Drugs
(☐
n/a)
☐Exper. Hx
☐Sig. Hx
☐Current
DEVELOP. HISTORY/ MILESTONES
☐No unusual prenatal events ☐Perinatal development within usual limits
EMPLOYMENT:
VOCATION/POST-GRAD PLANS:
LEGAL HISTORY
ARRESTS: ( ☐None reported)
CURRENT LEGAL ISSUES ( ☐None reported)
RISK ASSESSMENT
Allergies and Adverse Reactions to Medications:
Hx of Abuse and/or Victimization:
(☐No allergies/adverse reactions to medicines or other substances reported)
(☐Denied)
Suicidality: (☐Denied) ☐Ideation ☐Intent ☐Means ☐Plan ☐Attempts ☐Gestures
Homicidality: (☐Denied) ☐Ideation ☐Intent ☐Means ☐Plan ☐Attempts ☐Gestures ☐Person at risk:_______________________
HISTORY OF ☐Clinically significant fire setting
☐ cruelty to animals
☐physical aggression
3
☐AWOL behavior.