DREAMS AND VISION, LLC
SCREENING/ASSESSMENT
Client Name
Client Record:
Date of Assessment:
Presenting Problems:
Client Preference:
Client Strengths:
Medical Problems:
Family Medical Problems:
___________________________________________________________________________
___________________________________________________________________________
Medication
Dosage
Purpose
Admin. Instruction
Are you currently pregnant – Yes
No
Have you ever been pregnant – Yes
No
If yes, how many times?
How many living children ______
________
Allergies – None _______ Food ________ Airborne_________others___________
Medications
Prior Treatment History (MH/DD/SA, other Relevant)
Social History:
Family History:
Appearance:
Behavioral Evaluation:
Living Arrangement/Homelessness:
Employment Status:
Economic Issues:
Functional Evaluation:
Developmental Evaluation:
Intellectual Evaluation: ___________________Mental Retardation Yes____ No___
Educational Review: Grade Completed _________________Problems in school
Legal History: Criminal Record Yes______ No_______ Pending Charges: Yes___ No_____
Family Legal History:
Criminal Record Yes______ No_______ Pending Charges: Yes___ No_____
Probation: yes_____ No_______ other:
Psychological Evaluation:
Mental Status:
Family Mental Status:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Normal
Ataxia
Restlessness
Slurred Speech
Mute
Pacing
Agitation
Other
Normal
Ataxia
Restlessness
Slurred Speech
Mute
Pacing
Agitation
Other
Speech
Family Speech
o
o
o
o
o
o
o
o
o
o
o
o
Rate
Volume
Articulation
Coherence
Spontaneity
Note any abnormalities:
Rate
Volume
Articulation
Coherence
Spontaneity
Note any abnormalities:
Language:
o Naming objects
o Repeating phrases
o Other
Mood and Affect:
o
o
o
o
o
o
o
o
o
Normal
Euphoric
Depressed
Fearful
Anxious
Apathetic
Flattened
Labile
Angry
Change in Biological Functions:
o
o
o
o
o
None
Sleep
Nightmares
Appetite
Other
Abnormal/Psychotic Thoughts:
Family Abnormal/Psychotic Thoughts:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
None
Hallucinations
Delusions
Homicidal ideations
Suicidal ideations
Preoccupation
Ideas of reference
Other
Thought Processes:
o
o
o
o
o
o
o
o
o
Logical
Illogical
Tangential
Computation – Yes_____ No_____
Rate – Fast______ Slow_____
Pressured
Impaired
WNL
Abstract thinking
Associations:
o
o
o
o
Loose
Tangential
Circumstantial
Intact
Oriented:
o Time
o Place
None
Hallucinations
Delusions
Homicidal ideations
Suicidal ideations
Preoccupation
Ideas of reference
Other
o Person
o Not applicable
Attention/concentration:
o
o
o
o
WNL
Good
Poor
Other
Estimate intellectual functioning:
Family intellectual functioning:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
None
Hallucinations
Delusions
Homicidal ideations
Suicidal ideations
Preoccupation
Ideas of reference
Other
None
Hallucinations
Delusions
Homicidal ideations
Suicidal ideations
Preoccupation
Ideas of reference
Other
History of Abuse:
Family History of Abuse:
o
o
o
o
o
o
o
o
o
o
o
o
None
Physical
Sexual
Emotional
Neglect
Domestic violence, if abuse indicated,
by whom?
None
Physical
Sexual
Emotional
Neglect
Domestic violence, if abuse indicated,
by whom?
Other behaviors:
o
o
o
o
o
None
Antisocial behavior
Depressive behavior
Anxiety/stress
Manic behavior
Present danger to self:
o
o
o
o
o
None
Thoughts of suicide
Threats of suicide
Plan for suicide
Suicide attempts – Yes ______ No______ how many ______ other information
o Family history of suicide
If yes, explain _______________________________________________________________
___________________________________________________________________________
o Preoccupation with death
o Describe
Substance Abuse History:
Age of
1st use
Method
Current
Current
frequency AMT
used
Primary
Secondary
tertiary
Sign and Symptoms of addiction:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
None
Tolerance
Loss of control
Blackouts
Preoccupation
Withdrawal
Money problems
Medical advise
Morning drinking
Drinking alone
Attempts to stop
Use despite consequences
Excessive time spent using
Reduction in activities due to use
Other
Length
of binge
Date last Withdrawal
used
symptoms
Diagnoses:
AXIS I
/
/
AXIS I
/
/
AXIS II
/
/
AXIS III
AXIS IV
AXIS V
Signature:
Date: