Agency Name:
Behavioral Health Assessment – BHA
(Based on Fields on AKAIMS BHA)
Headings in Black are Medicaid requirements.
Information in Blue is what might be included under each heading. (This is not an inclusive list. You
may wish to include other material that you consider important to the assessment process.)
Date of Assessment: ________________
IDENTIFYING INFORMATION (FROM AKAIMS INTAKE & PROFILE)
Name: _____________________________________________________________________________
Age: ___________
DOB: ______________
Ethnicity: ________________________________
Address: ___________________________________________________________________________
Phone #:_____________________________
Cell #:___________________________________
ALERTS (primary language, needs translator or other special accommodations):
INTAKE AND SCREENING METHODS USED: ___Face to face interview _____Family Input
_____AST _____Risk Assessment
_____Medical Questionnaires _____Fall Risk Assessment _____Chart Review _____CSR
_____Collateral Info from:
Results of risk assessment: _____No risk identified/reported _____Safety Plan developed
_____Referred to Emergency Services
_____Mandated report made to law enforcement _____Duty to Warn completed _____Other:
Results of Alaska Screening Tool (AST):(Regulations require a statement of how AST was considered
during development of the assessment. There is no designated area for this information. The assessment
could contain a separate area for this information or it could be included in an already established area of
the assessment, such as the Functional Impairment area.
Results of Client Status Review (CSR): ):(Regulations require a statement of how the CSR was
considered during development of the assessment. There is no designated area for this information. The
assessment could contain a separate area for this information or it could be included in an already
established area of the assessment, such as the Functional Impairment area.
Presenting Problem ( In AKAIMS, the Presenting Problem populates from the Intake and in order
to make changes you must go to there and make the necessary changes.)
This section contains both the client’s direct statements of their concerns and/or presenting problem(s)
and the clinician’s understanding of the presenting problem(s). Use the client’s words “quotes”. It is
possible that you will have a third understanding of the problem (s) if the client is not self-referred i.e.
court ordered or office of children’s services. In AK AIMS the Presenting Problem is entered at intake
and the staff who conducts the Behavioral Health Assessment (BHA) must add to the information that is
entered at Intake. The presenting problem must reflect the symptoms as well as the problem. The
symptoms of the problem will become the goals for treatment.
MAY INCLUDE:
Symptoms and their severity
Onset of symptoms
Client ID #:
Duration of symptoms
Precipitating factors
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Agency Name:
Frequency of symptoms(Daily, weekly, etc.)
What has client tried in order to correct
Client statement: (in client’s own words)
Clinical understanding of presenting problem: (Understanding of client statement of problem including
symptoms, current life stressors, including onset/duration of symptoms and current efforts to manage
problem)

Family HX (relevant family history of mental illness, incarcerations, deaths, divorce, substance
abuse, domestic violence and/or sexual abuse)
Family Hx of illnesses/diseases:
Family Hx of Mental Illness:
Family Hx of substance use:

Client History and Current Status (The history included in each section should be relevant to
behavioral health problems. This section should, in combination with presenting problems, begin
to build the basis for a diagnosis and for a problem list.)
Finances and Housing (Drop downs only in AKAIMS): (may include where the client lives,
for how long, if it is temporary or permanent, and client’s feelings regarding her/his residence)
Legal Hx/Current Involvement: (past/current arrests, charges/dropped charges, restraining
orders against individual, OCS involvement, financial difficulties, etc.)
Family/Peers: (consequences/influence of family/peer use on individual, historical/current role in
family, historical/current family or household demographics, significant family/peer experiences,
etc. Family composition, guardianship issues, also include information regarding consumer’s
interpersonal relationships and their ability to get along with their peers. May include genogram
here if you choose to do so.)
Education/Work: (educational background, difficulties in school, desired area of
study/employment, work history, military service)
Summarize consumer’s history of functioning in these settings and how successful they have
been.
MAY INCLUDE:
Highest grade completed
If client is student, how is performance?
Employment type
Functioning level at work
Duration of employment
If not working, is client seeking work?
Number of jobs held in recent months
What type position would client desire?
Medical: (historical/current medical issues, TBI, FAS/FAE, family medical issues, head trauma,
allergies, nutritional concerns, ability to self-care and live independently, physiological sexual
Client ID #:
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Agency Name:
dysfunction, etc. Basic medical information to include a statement of significant health history or
lack thereof.
MAY INCLUDE:
Current and past major illness
Hospitalizations
Current medications
Major injuries)
Current Physical Pain Level (by client report):
“I have no
pain.”
I have a little
2
pain.”
“I have some
4
pain.”
(moderate)
“I have a lot of
6
pain.”
“I have severe
8
pain.”
“I have very
10
severe pain.”
Current MH Rx medications:
Current Medications:
NAME
DOSAGE
0
___Referral to Nutritionist
___Referral to Medical/Eye/Dental
___Referral to Health Department
___Referral to Dev. Disabilities
Neurological/Other Disabilities (history of head trauma,
periods of unconsciousness, disabilities and known
causes, cognitive functioning
ROUTE
FREQUENCY
COMPLIANCE/EFFICACY
Mental HX and Current Status: Historical/Current Trauma Issues (including loss of family
members, sexual assault, childhood abuse, domestic violence, etc. If there is knowledge of past
mental health/psychiatric treatment provide a description of the problems, treatment, and
outcomes. I.e. what’s been tried and what was the result/how successful was it. This information
may come from clinical staff, records, or the consumer/family directly. Also do a family history
and any suicide or homicidal ideation reported by client Ask client to sign ROI’s to obtain recent
medical history if information is needed for treatment.)
Drug and Alcohol HX and Current Status: (use and influence of substances on past and current
functioning, use and influence of substances on past and current job-related incidents Conduct
ASAM Level of Care.)
SUBSTANCE USE HISTORY
Age of Onset
Duration
Pattern of Use/Date of Last Use
Alcohol use:
Drug use:
Nicotine use:
Client ID #:
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Agency Name:
Other addictive behaviors:
Previous or current symptoms reported: ___Tremors ___Nausea/Vomiting ___Diarrhea
___Hallucinations ___Insomnia ___Seizures ___Agitation ___Depressed mood ___Mood
swings ___Intense cravings ___Blackouts ___DTs ___Memory loss ___Using more due to
reduced effect ___Unsuccessful attempts to cut down or stop use ___Less time spent on
interests ___Using in spite of adverse consequences ___Using more/longer than intended
___Difficulty managing triggers ___preoccupation with using/cravings



TREATMENT HISTORY
Treatment Provider
(MH or AODA)
Dates of treatment
Response to Treatment
Relapse
Comments
______________
__________________
____________________
__________________
______________
__________________
____________________
__________________
Functional Impairment (functional assessment of relationships with others in various settings,
drug-seeking behaviors, problematic social situations, hobbies/interests, leisure/recreational
activities, ability to function successfully in family, community and work/school, etc. Functional
impairments must be considered when planning treatment. (Addressing the Alaska Screening
Tool (AST) and the Client Status Review (CSR) results is a Medicaid requirements and this
information could be included here.)
Developmental History (include prenatal care that assesses for FAS/FAE if applicable) :
(Gather information regarding developmental milestones such as standing, walking, running,
toilet training and talking (whether they appear to have been achieved within normal limits or
not).
Mental Status Exam (Must be conducted by a Mental Health Professional Clinician): (This
section may include very basic observations pertinent to mental status for many clients, or contain
a more detailed examination for those with more severe or complex symptoms. The information
in this section should assist in diagnosing, be congruent with the listed diagnosis, and be useful in
formulating interventions and treatment strategies.
OBSERVATIONS TO BE CONSIDERED INCLUDE:
general appearance; posture; hygiene; eye contact; speech patterns; affect; recent & remote
memory; thought association; insight and judgment; cognitive processing; presence or absence of
hallucinations, orientation to time, place, person, and situation; suicidal homicidal ideation plans
and previous attempts, expression of and management of negative emotions, communication
style, symptoms generally associated with depression or anxiety, coping style, intimacy issues,
etc.)

Clinical Impressions Summary: (Think of the clinical impression as the information that the
clinician notes as important in order to develop a Multi Axial Diagnosis. Your clinical
interpretation is based on the contents of the assessment and supports symptoms described in
assessment and supports the diagnosis. It is a summary of the reason client needs treatment and
Client ID #:
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Agency Name:
services. Provides criteria to justify diagnosis, medical necessity for services, risk of harm, and
how individual will benefit from proposed treatment recommendation)
 Eligibility Summary: (This contains the symptoms and the dx information that support that the
client is eligible for the level of services that you are recommending. There are specific Medicaid
requirements for recipient eligibility for rehabilitation services and this is the area where you
support that need.)
Problem Summary List: (The regulations require that you document problems but do not
specify a Summary List; however, AKAIMS requires a list and the contents populates to the
treatment plan)
List the problems identified in the assessment (Presenting Problems, other identified problems;
consider impact of functional impairments).
Be sure to include the symptoms of the problem as the symptoms become the goals for treatment.
The key to writing measurable goals is to be specific in stating the problems in the assessment.
Vague problems result in vague goals that in turn result in vague progress notes. For example, to
state that a client fights with peers without further clarification is almost meaningless. Does the
word fight refer to fist fights, legitimate arguments or intense bouts of serious name-calling and
verbal abuse? How often does this happen? What was the most severe consequence that arose
from a fight?
Note how much clearer the problem is defined in the following excerpt from his assessment:
When John perceives himself as likely to be embarrassed in front of others, he attempts to avoid
this feeling by lashing out at the person who he feels is responsible. Situations that may result in
his lashing out include being called on in class when he doesn’t know the answer, being
confronted when he is talking to others instead of doing his work and bantering with peers when
John feels they have gone too far. Regarding this latter issue, John is seen as someone who can,
“Dish it out but can’t take it” when others verbally defend themselves. During these times, he
shifts the responsibility for the problem onto others by raising his voice, cussing and posturing in
a way that is physically intimidating to others. Even though he has not actually hit anyone, other
students and on some occasions, even teachers, have feared that they might be hit. John has
already received a suspension for his behavior on one occasion. These problems occur mostly at
school, but he has had problems in the community (Getting thrown out of K Mart for yelling at a
clerk) and at home (Yelling and posturing as if he was going to hit his mother).
In an actual intake there would be much more information and the above is not meant to be
comprehensive, but rather to provide an example of problem identification in order to
write clear goals and measurable objectives.
Here are some clearly stated problems based on the above information:
1)
Client ID #:
John uses intimidation, specifically raising his fist, posturing, cussing and raising his voice
to avoid and escape situations that he sees as embarrassing.
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Agency Name:
2)
John is at risk for school failure due to suspensions. He was suspended last week.
3)

John experiences secondary gains from his use of anger He expressed that he sees himself
as respected rather than feared)
Strengths/Resources:
Religion/Spirituality (describe the individual’s perception of the role of religion or spirituality in
his or her life):
Cultural Considerations (cultural preferences, importance to individual, approach to substance
use/addictive behaviors and treatment, etc.):
Use of Community Resources (individual needs and past/current social/interpersonal supportive
resources accessed by individual):
Readiness for Treatment (describe the internal and external source of motivation to complete
treatment, pre-contemplation/contemplation, planning/action stage, barriers to treatment, etc.)
Last best functioning period in lifetime:
What needs to happen for individual to function at his or her best again?

Client Diagnosis
Primary
Secondary
Tertiary
Axis I: Clinical Disorders
Axis II: Personality Disorders/Mental Retardation
Axis III: General Medical Conditions -The therapist or counselor will not make a medical dx as
this requires a doc or at least someone with prescription authority. You can document the
information collected on AXIS III as “by client report” or “by history in chart”, etc.
Axis IV: Psychosocial and Environmental Problems as listed below. (Be sure to specify the
condition that applies to the client. You could use an “as evidenced by (aeb) or “due to”
statement. An example would be: The client is experiencing relationship problems as evidenced
by (aeb) constant verbal altercations with family and friends.)
–
–
–
–
–
–
–
–
–
Family Conflict:
Health:
Housing:
Legal Conflicts:
Occupational Problems:
Relationship Conflict:
Economic:
Educational Deficit:
Family Conflict:
Client ID #:
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Agency Name:
– Social Environment:
Axis V: Global Assessment of Functioning (GAF) (The GAF Scale (from DSM) measures
client’s level of functioning based on symptoms and ability to function in their current
environment. A client might test higher when in a hospital where the environment is controlled.
However, if the client is now returning to the community, you should base this on his current
environment. It is recommended that you use the GAF Tree (available from your agency or by
contacting the Division of Behavioral Health) to assist in determining this score.)




Prognosis (Drop down boxes in AKAIMS):
Comments (support for prognosis): (Discuss your prognosis.)
Services the Family Wants: (Areas to Work on - as identified by individual/family, what
individual/family wants to see accomplished in the short- and long-term)
Recommendations (Identify Medicaid services to be used): (specific services—what problem
will be addressed with the service i.e. individual counseling to address “problem” — other
screening/assessments— referrals to be made—medical/eye/dental, etc.)
Substance abuse services recommended as a result of this assessment include:
ASAM Level of Care:
Actual Placement Recommendation:
Clinical
Justification:
Recipient Support Services IS / IS NOT recommended. (If recommended you must
document the support for your recommendation.)
Services deferred and reason for deferral (If you identified a problem that you do not intend to
address on the current treatment plan please include a justification as to why the problem is not
being addressed at this time.)
Preliminary discharge plan (what will individual have accomplished to show readiness for
discharge, what additional considerations need to be made prior to discharge. This a requirement
in the treatment plan and may be added to assessment in preparation for development of plan.)
__________________________________________________
Staff Signature with credentials
____/____/20____
Date
__________________________________________________
Staff Name Printed
__________________________________________________
Signature of Supervisor with credentials (if required)
Client ID #:
____/____/20____
Date
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