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
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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
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