Anywhere School Health Center
Address
Phone
Behavioral Health Services - Child/Adolescent Assessment
Student’s Name:
D.O.B:
Referred by:
Grade: ____
Chart #: _____________
Chief Complaint (Reason for Referral/Presenting Problem):
 Academic  Behavior  Peer Relationships  Family Relationships
 Substance Abuse  Physical/Sexual Abuse
 Other Stressors
Living Situation:
 Both biological parents
 Grandparent(s)
 Other:
Other persons living in home:
 One parent
 Foster parent
 Step parent in home
 Juvenile home
Who has legal custody:
School Academics/Behavior:
 General Studies
 Vocational
 Special Education/Remedial Class
 Alternative Program  Retained in Past  Suspensions/Detentions
 Problems with teachers
 Problems with peers
 Other/Comments:
Favorite classes and why:
Least favorite classes and why:
Academic Performance:
Previous Academic Performance:
 Outstanding
 Outstanding
WV School Health Technical Assistance and Evaluation Center
Marshall University
 Satisfactory
 Satisfactory
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 Failing
 Failing
Substance Use:
Tobacco
Caffeine
Acid
RX pills
Age of first use:
Alcohol
Marijuana
Other:
Frequency:
Patient thinks substance abuse is a problem for him/her:
Alcohol/Substances have been a problem for other family members:
Yes
Cocaine
No ___
Yes
No ___
Medical History/Medications:
Mental Health Services/Medications:
Other services patient is involved in:
 DHHR
 Other Counseling Services
Social/Community/Interests & Hobbies:
 Has many friends  Has best friend
 Has friends over to home
 Spends time at friend’s home
 Attends community functions
Leisure Interests:
Sexual Behaviors/Issues:
Sleep Patterns:
Has difficulty sleeping
Yes
No
If yes, patient displays:
 Nightmares
 Frequent waking
 Early morning wake-up
 Excessive time falling asleep
 Insomnia  Night terrors
Weight or Food Issues:
 Overweight
 Underweight
WV School Health Technical Assistance and Evaluation Center
Marshall University
 Satisfied with weight/body
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1/18/07
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Patient Name:
Chart #:
Strengths and Resources:
Assessment/Preliminary Diagnosis:
Treatment Type:
 Individual  Family
Solution Focused Therapy
Insight
Behavioral
Cognitive
 Group
Homework given
Family
Relationship
Problem Solving
Frequency:
Support
Education
Resource Linkage
Advocacy
Additional Comments:
Plan/Homework:
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/07
116094714
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MENTAL STATUS/BEHAVIORAL ASSESSMENT
Conversation:
 Relevant  Free Flowing  Irrelevant  Guarded  Rambling
 Other
Affect:
 Flat  Blunted  Appropriate  Labile
 Broad
 Restricted
 Inappropriate
Mood:
 Normal
 Euphoric  Euthymic  Elated
Depressed  Anxious
 Irritable
 Expansive  Dysphoric  Other:
Mood and Affect:
 Congruent
 Incongruent
Speech:
 Soft
 Loud
 Pressured  Audible
 Inaudible
 Rapid
 Slurred
 Slow
 Stuttering  Other:
Psychotic Symptoms:
 None
 Auditory Hallucinations  Visual Hallucinations
 Tactile Hallucinations
 Olfactory Hallucinations  Other:
Thinking:
 Appropriate  Loose Associations  Flight of Ideas
 Slow
 Delusional
 Ideas of Reference  Preoccupied
 Homicidal
 Suicidal
 Disoriented
 Poor Concentration
Behavior and Manner:
 Cooperative  Established Rapport  Polite and Courteous
 Sociable
 Eye Contact
 Uncooperative
 LOA
 Rude
 Evasive
 Posture
 Fidgety
 Lethargic  Easily Distracted
 Short Attention Span
 Intrusive  Talkative  Oppositional Behavior
 Aggressive Behavior
 Fine Motor Coordination  Gross Motor Coordination
Appearance:
 Appropriate  Clean  Neat
 Casual
 Formal
 Untidy
 Glasses
 Visual Problems
 Hearing Problems  Motor Problems
 Appearance in relation to age:
 Clothing style:
 Reviewed limits of confidentiality
 Parental Consent in chart
Scores from Objective Survey (HAD, CDI, Connors, etc.)
 Yes
Children’s Developmental Questionnaire:
Issues from GAPS Screening:
Counselor:
 No
 N/A
Date: __________
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/07
116094714
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