Client Name:
Date:
Parent/Guardian Present:
Other people present:
Other sources of information used:
Session duration:
Location:
======PRESENTING PROBLEM======
Current functioning:
Stressors/precipitating events:
Reported symptoms:
======BIO PSYCHO SOCIAL======
History of functioning:
School (name, grade, IEP/504, failures, suspensions, absences):
Living situation:
Family composition (siblings, relationship w/ bio parents, visitation):
Social/interpersonal functioning:
Strengths:
Protective factors:
Weaknesses/challenges:
Interests:
Cultural/spiritual:
Gender/sexuality:
======MEDICAL AND MENTAL HEALTH HISTORY======
Primary Care Physician and other providers:
Major health issues/diagnoses:
History of injuries and hospitalizations:
Mental health history (past symptoms and services, including outcomes and barriers; past diagnoses):
Medications past and present:
Developmental history (milestones, etc):
Issues or complications with pregnancy and birth/delivery:
Family mental health history:
======TRAUMA HISTORY======
Major stressful or traumatic events:
Trauma symptoms:
Legal history (DSS/CPS, DJJ, police involvement):
======RISK ASSESSMENT======
Suicidality/self-injurious behavior (past and present):
Homicidality/aggression (past and present):
Substance use (past and present):
Other high risk behaviors:
Supervision issues/needs:
Safety in home/community:
======CLIENT/GUARDIAN PRESENTATION AND PARTICIPATION======
Mental Status Exam:
Client participation:
Parent/Guardian participation:
======CASE FORMULATION======
======TREATMENT RECOMMENDATIONS======
Based on this assessment, therapist recommends...
[ ] Individual therapy
[ ] Family therapy
[ ] Group therapy
[ ] Higher level of care in the form of ________