ATTACHMENT, SELF-REGULATION AND COMPETENCY (ARC) TRAUMA ASSESSMENT OUTLINE OHU 960 Client Name: Caregiver/Parent Name: Client Date of Birth: Emergency Contact: Emergency Health Needs: Legal Status: Therapist: Date of Report: Paper and Pencil Instruments: Child Behavior Checklist, Parenting Relationship Questionnaire, Trauma Symptom Checklist for Children, Youth Self Report, Children & Adolescents Needs and Strengths (CANS) Mental Status Examination (circle those that apply) Physical Appearance Build: Height: Hygiene: Clothing: thin short clean neat medium medium disheveled untidy athletic tall odorous peculiar heavy obese Motor Activity Within normal limits restless agitated psychomotor retardation Attention:/Concentration Thought Content Within normal limits fair distractible very poor Ox3 disoriented to time disoriented to place disoriented to person Rate: within normal limits slow pressured Rhythm: within normal limits monotonous sing-song Volume: within normal limits loud soft Range: within normal limits broad constricted liability evident Intensity within normal limits elevated diminished Calm relaxed euphoric trusting other: Irritable anxious apathetic guarded Angry fearful dysphoric suspicious Friendly cooperative dependent engaging other: Timid evasive demanding histrionic Hostile resistant arrogant seductive Within normal limits loose association tangential incoherent Logical illogical confused magical thinking bizarre Relevant digressive rambling circumstantial flight of ideas Fluent blocking perseveration unresponsive Informative vague impoverished other: Within normal limits delusional beliefs (describe): Perceptual None Orientation Speech Affect Mood Demeanor Thought Processes OHU 960 New 4/2015 derealization depersonalization 1 ATTACHMENT, SELF-REGULATION AND COMPETENCY (ARC) TRAUMA ASSESSMENT OUTLINE OHU 960 Disturbances Dangerousness to Self (Check all that apply, document positive response) Dangerousness to Others (Check all that apply; document positive response) Hallucinations: auditory visual olfactory tactile none ____ No indicators of risk ____ Experiences of suicidal ideation without any prior attempts (frequency: ___) ____ History of suicide attempts (# of times: unknown) ____ Current fleeting/occasional suicidal ideation without plans or rue intent ____ Current suicidal ideation and has conceived of plan ____ History of self-mutilation ____ Current pattern of self-mutilation __ No indicators of risk ____ History of poor control over aggressive/homicidal impulses ____ History of legal/interpersonal/occupational difficulties related to aggressive/homicidal behavior ____ Current legal/interpersonal/occupational difficulties related to aggressive/assaultive/homicidal behavior ____ Current impulses/ideation of an aggressive/assaultive/homicidal nature without plans or true intent ____ Current impulses/ideation of an aggressive/assaultive/homicidal nature with plans or true intent Behavioral Observations Social History and Background ( Include religious, ethnic, cultural background, sexual orientation if appropriate, developmental level, and military status of family) Trauma Experiences Mental Health Symptoms (Include any medications that the client may be prescribed and treating psychiatrist/doctor) Attachment, Self-Regulation, and Competence (ARC) Framework Attachment Caregiver management of affect Attunement Consistent Caregiver Response Routines and Rituals Self-Regulation Affect Identification Modulation Affect Expression Competency OHU 960 New 4/2015 2 ATTACHMENT, SELF-REGULATION AND COMPETENCY (ARC) TRAUMA ASSESSMENT OUTLINE OHU 960 Executive Functions Self-Development and Identity Summary and Recommendations ( Including any recommendations to address co occurring mental health or substance use/abuse issues) DSM IVTR Codes Multiaxial Diagnoses Diagnosis Axis I Axis II Axis III Axis IV Axix V Psychosocial stressors (circle all that apply) Problems with: primary support group economics Social environment access to health care services Education interaction with the legal system Occupation other: Housing Current: unknown GAF past 12 months: ____________________________________ Therapist Signature _______________ Date ____________________________________ Supervisor Signature _______________ Date OHU 960 New 4/2015 3