CLINICAL ASSESSMENT
Consumer:
Case #:
Start Time:
Stop Time:
Date:
Presenting Concerns/Historical Concerns:
Potential Medical Complications Related to Mental Status:
History of Substance Use:
Yes
No; (If Yes, update/complete SUD Chart):
History of Mental Health/SUD Treatment:
form):
Yes
No; (If Yes, update/complete History of Mental Health/SUD Treatment
a.
Prior Diagnosis:
b.
Prior Response to Treatment/Medication:
Lethality/At Risk:
a. Suicidal/homicidal thoughts, gestures, plan: Yes
No; If Yes, complete Lethality Assessment
b. Self Care Issues: Yes
No; If Yes, see diagnostic formulation
c. Duty to Warn: Yes
No; If Yes, indicate who was notified, when, and by what method:
Clinical Assessment
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Form #1002
Rev: 1/14
Consumer Name: ______________________
Case Number: ________________
Mental Status Exam:
Status – degree of distress/disturbance/dysfunction
Appearance:
Grooming
Clothing
Unusual Physical Characteristics
Comments on Appearance:
1-Unremarkable
2-Minor
3-Moderate
4-Severe
Status – degree of distress/disturbance/dysfunction
Behavior:
1-Unremarkable
2-Minor
3-Moderate
4-Severe
Posture
Facial Expression
General Body Movements
Amplitude and Quality of Speech
Provider – Consumer Relationship
Comments on Behavior:
Status – degree of distress/disturbance/dysfunction
Affect/Mood:
1-Unremarkable
Range
Spontaneity
Appropriateness
Comments on Affect/Mood:
Clinical Assessment
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Rev: 1/14
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2-Minor
3-Moderate
4-Severe
Consumer Name: ______________________
Case Number: ________________
Status – degree of distress/disturbance/dysfunction
Perception:
1-Unremarkable
2-Minor
3-Moderate
4-Severe
Delusions
Hallucinations
Comments on Perception:
Status – degree of distress/disturbance/dysfunction
Thinking:
1-Unremarkable
Intellectual Functioning
Orientation
Insight
Judgment
Memory
Thought Content
Stream of Thought Manifested in Speech
Comments on Thinking:
Mental Status Exam Summary:
Clinical Assessment
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2-Minor
3-Moderate
4-Severe
Consumer Name: ______________________
Case Number: ________________
Diagnostic Formulations; including as appropriate, differential diagnosis and diagnostic formulations of family functioning:
DSM IV Diagnosis:
Axis I:
Primary
Secondary Tertiary
SA Primary
SA Secondary
DSM-IV / Description
Axis II:
Primary
Secondary
DSM-IV / Description
Axis III (qualifying/state reported axis III information only):
Primary
Secondary Tertiary
DSM-IV / Description
Axis IV:
Economic problems
Problem with primary support group
Problem accessing healthcare
Problem related to social environment
Educational problems housing problems
Problem related to interaction with legal system
Occupational problems
Other psychological and environmental problems
Housing problems
Axis V: Current GAF
Diagnostic Summary:
Diagnosis made by:
Prognosis:
Good
Clinical Assessment
Form #1002
Rev: 1/14
Date:
Fair
Poor
Last Update:
Guarded
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Consumer Name: ______________________
Case Number: ________________
Specific Clinical Recommendations:
Clinician Signature/Credentials
Date
Psychiatric Signature
Date
Supervisor Signature (optional)
(Required for all BC/BS, Medicare cases within 10 days from date of assessment)
Clinical Assessment
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Rev: 1/14
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Date