Clinical Assessment Clinician: Client ID# Primary Configuration: Primary Language: Other: List client and significant others Adult(s) 1. Gender: Age: Ethnicity: Relational Status: Occupation: Other identifier: 2. Gender: Age: Ethnicity: Relational Status: Occupation: Other identifier: Child(ren) 1. Gender: Age: Ethnicity: Grade: School: Other identifier: 2. Gender: Age: Ethnicity: Grade: School: Other identifier: Others: Presenting Problems Alcohol/drug use Anger issues Divorce adjustment Loss/grief Anxiety/worry Eating problems/disorders Major life changes Remarriage adjustment Couple concerns Job problems/unemployed Parent/child conflict Sexual abuse/rape Depression/hopelessness Partner violence/abuse Sexuality/intimacy concerns Other: Complete for children: Child abuse/neglect Fighting w/ peers School failure/decline performance Hyperactivity Truancy/runaway Isolation/withdrawal Wetting/soiling clothing Other: Mental Status Assessment for Identified Patient Interpersonal Conflict Other: Mood Enmeshment Harassment Legal issues/probation Isolation/avoidance NA Suicidal thoughts/attempts Angry Anxious Depressed/Sad Dysphoric Irritable Manic NA Other: Affect Blunt Constricted Flat Incongruent Labile NA Other: Sleep Disrupted Hypersomnia Insomnia NA Nightmares Other: Eating Anorectic restriction Binging Decrease Increase NA Purging Other: Anxiety Chronic worry Compulsions NA Obsessions Panic Phobias Other: Trauma Symptoms Avoidance efforts Dissociation Flashbacks/Intrusive memories Hypervigilance NA Other: Psychotic Symptoms Delusions Hallucinations Loose associations NA Paranoia Other: Motor activity/Speech Agitated Hyperactive Impulsive Inattentive Low energy NA Pressured speech Slow speech Other: Thought Concrete Denial Poor concentration Disoriented Poor insight Impaired decision making Ruminative Self-blame NA Other-blame Tangential Numbing Other: Socio-Legal Arrest/incarceration Defiant Disregards rules Initiates fights Lying NA Stealing Tantrums Other: Other Symptoms Diagnosis for Identified Patient Contextual Factors considered in making diagnosis: Addiction Age Family dynamics Cognitive ability Gender Culture Immigration Dual diagnosis/comorbid Language Religion Economic Sexual/gender orientation Trauma Other: Describe impact of identified factors on diagnosis and assessment process: DSM-5 Code Diagnosis with Specifier Include V/Z/T-Codes for Psychosocial Stressors/Issues 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. Medical Considerations Has patient been referred for psychiatric evaluation? No Yes Has patient agreed with referral? NA No Yes Psychometric instruments used for assessment: Cross-cutting symptom inventories None Other: Client response to diagnosis: Agree Disagree Not informed Somewhat agree If not informed, state reason: Current Medications (psychiatric & medical) NA 1. ; dose mg; start date: 2. ; dose mg; start date: 3. ; dose mg; start date: 4. ; dose mg; start date: Medical Necessity: Check all that apply Probability of significant impairment Probable developmental arrest Significant impairment Areas of impairment: Daily activities Health Living arrangement Other Social relationships Other: Risk and Safety Assessment for Identified Patient Work/School Alcohol Abuse Homicidality Suicidality Current Active ideation No indication/denies Active ideation Cruelty to animals Past abuse Attempt in past year History of assaulting others Family or peer history of completed suicide If current, freq/Amt: Ideation in past year Drug Use/Abuse Ideation in past year Intent with means Intent with means Intent without means Current No indication/Denies Family/sig.other use Passive ideation No indication/denies Violence past year Past use Intent without plan No indication/Denies Passive ideation If current, drugs: freq/Amt: Sexual & Physical Abuse and Other Risk Factors Adult with abuse/assault in adulthood Cutting or other self harm Childhood abuse history Criminal/legal history Elder/dependent adult abuse/neglect History of or current issues with restrictive eating, binging, and/or purging None reported Other trauma history Childhood abuse history: Emotional Neglect Physical Adult with abuse/assault in adulthood: Current Physical Sexual History of perpetrating abuse: Emotional Physical Sexual Cutting or other self harm: Current Method: Method Past Sexual History of perpetrating abuse Criminal/legal history: Other trauma history: Indicators of Safety Able to cite specific reasons to live or not harm At least one outside support person Developing set of alternatives to self/other harm Sustained period of safety Has future goals Hopeful NA Other Willing to dispose of dangerous items Willing to implement safety plan, safety interventions Willingness to reduce contact with people who make situation worse Other: Indicate period of sustained safety: Elements of Safety Plan Emergency contact card Emergency therapist/agency number Medication management NA Other Plan for contacting friends/support persons during crisis Specific daily/weekly activities to reduce stressors Specific plan of where to go during crisis Specific self-calming tasks to reduce risk before reach crisis level (e.g., journaling, exercising, etc.) Verbal no harm contract Written no harm contract Other: Legal/Ethical Action Taken Action NA Action Taken: Case Management Collateral Contacts Has contact been made with treating physicians or other professionals: In Process NA Yes Name/Notes: If client is involved in mental health treatment elsewhere, has contact been made? In Process NA Yes Name/Notes: Has contact been made with social worker: In Process NA Yes Name/Notes: Referrals Has client been referred for medical assessment: No evidence for need Yes Has client been referred for social services: Job/training Legal aid Medical NA Other Other: Has client been referred for group or other support services: In process None recommended Yes Are there anticipated forensic/legal processes related to treatment: No Yes describe: Support Network Client social support network includes: Victim services Welfare/Food/Housing Friends Other Religious/spiritual organization Supportive family Supportive partner Supportive work/social group Other: Describe anticipated effects treatment will have on others in support system (Children, partner, etc.): Is there anything else client will need to be successful? Expected Outcome and Prognosis Anticipate less than normal functioning Prevent deterioration Return to normal functioning Client Sense of Hope: (1=Little Hope, 5=Moderate Hope, 10=Hope high) 1 2 3 4 5 6 7 8 9 10 Evaluation of Assessment/Client Perspective How were assessment methods adapted to client needs, including age, culture, and other diversity issues? Describe actual or potential areas of client-clinician agreement/disagreement related to the above assessment:
