CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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Identifying Information
Admission Date:
DOB:
Client Name:
Last
First
Age:
MI
Primary Language:
School:
Referred By:
Secondary Language:
Grade:
Ethnicity:
Person or Agency Name, Phone #
Parents Name
Parents Name
Parents’ Primary Language:
Address
Phone #
Address
Phone #
Legal Guardian/Foster Parent’s Name
Guardian/Foster Parent’s primary Language
Ward or Dependent of Court:
Informant:
Address
Phone #
Relationship
Language:
Relationship:
Reason for Referral/Chief Complaint
Why Referred
Current Primary
Symptoms/Behavior
Describe Onset &
Duration
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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History
I.
History of Presenting Problem
Symptoms/Behaviors
How a problem
Parents perception
of cause
Attempted solutions
Relevant Factors
Environment
(School/Home)
Relationships
(Loss/Separations)
Traumatic Events
Sexual/Physical Abuse
Sleep Patterns
Eating Patterns
Hygiene Changes
Problem Suggestive of:
MR
LD
PDD
ADD & Disruptive
Behavior
Feeding & Eating
Tic
Communication
Elimination
Other
Schiz/Psychotic
Mood
Anxiety
Neurological
II. Additional Problem Areas/Associated Behaviors
Peer Problems
Other
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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8
History (continued)
III. Prior Mental Health History
Suicidality/Homicidality
Interventions
When
Where
Type
Duration
Medication: dosage,
response, adverse
reactions
Recommendations
Response to Treatment
Parent and Child
Satisfaction
IV.
Illness (Acute/Chronic)
Medications
Allergies
Accidents
Head Injuries
Seizure
Pregnancy
Sexually Transmitted
diseases
HIV
Vaccinations
Hospitalizations/Surgeries
Vision/Hearing
Dental Health
V.
Substance Use Overview & Attitudes/Exposure (family & peers experience)
MH554 Substance Use Self-Evaluation Completed:
Yes
No, Explain:
MH552 Parent/Caregiver Questionnaire Completed:
Yes
No, Explain:
Medical History
Pediatrician name
Phone
Last Exam:
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Glasses:
Yes
No
Name:
MIS#:
Agency:
Prov#:
Braces:
Yes
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
No
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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8
History (continued)
VI. Developmental History
Neonatal:
Prenatal Care?
Place of delivery
Term: Mos.
Age of Mother
Birth Wt.
Age of Father
Marital Status
Did mother use alcohol, cigarettes, drugs? Specify:
Illness, accidents, stresses during pregnancy or at the time of delivery
Type of Delivery
Duration of Labor
Post partum complications
Comments (Include family and environmental stressors during pregnancy and birth):
Developmental Milestones
(Describe if not within normal limits)
Infancy (0-3)
Motor – sit, crawl, walk
Speech; Eat; Sleep
Toilet training
Coordination
Temperament
Separation
Environmental Stressors
moves; schools; separation; losses of fam/ friends,
changes in fam composition, SES, lifestyle;
exposure to fam conflict/violence; major illnesses;
abuse; placements, etc.
Infancy (0-3):
Early Years (4-6):
Early Years (4-6)
Social Adjustments
Separation
Sexual Behaviors
Latency (6-11)
School adjustment
Peer & adult
relations/friends
Interest/Hobbies
Impulse control
Latency (6-11):
Adolescence (12-on)
Separation/Individ.
Sexual Ident./beh.
Relationships
Independent func.
Moral develop.
Adolescence (12-on)
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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History (continued)
VII.
Type of School
Academic Performance
Grade Retention
School Changes
Age & Grade
Attitude/Behavior
Attendance/Truancy
Suspension
School History Special Education
Current/Past IEP and Date
AB 3632:
Yes
No Services:
Arrests
Offenses
Probation
Current/Prior
Incarceration
Placement
VIII.
Juvenile Court History
Nature of Abuse
Age of occurrence
Offender
CPS or Police
Intervention
Dependency Court or
Criminal Court
Action
Child Response
Parents response to
disclosure
Placements and type
IX.
Child Abuse & Protective Services History
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Special Classes
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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History (continued)
X.
Relevant Family History & Current Living Situation
Indicate nature of family group being described: Biological, Adoptive Guardian, Foster, Group
Family Composition
Marital Status
Siblings/Grandparents
Ethnicity/Culture
Education
Occupation
Socio-Economic
Family History
Medical
Psychiatric
Drug/Alcohol
Legal/Criminal
Family Relationships
(Current and
Intergenerational)
Disciplinary Style
Conflict/Violence
Family Strengths
Child & Family/Significant Other Reflections
Family/Child’s perceived needs and expectations within the context of their culture
What are family
members/child:
Expecting of MH
Expecting from
Interagency system
Willing to contribute
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
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Mental Status
Provide a word picture of this child based on your observations.
Include relevant features from column on left.
Appearance
Dress, grooming, unusual
physical characteristics
Behavior
Activity level, mannerisms, eye
contact, manner of relating to
parent/therapist, motor
behavior, aggression,
impulsivity
Expressive Speech
Fluency, pressure, impediment,
volume
Thought Content
Fears, worries, preoccupations,
obsessions, delusions,
hallucinations
Thought Process
Attention, concentration,
distractibility, magical thinking,
coherency of associations, flight
of ideas, rumination, defenses
(e.g. planning)
Cognition
Orientation, vocabulary,
abstraction, intelligence
Mood/Affect
Depression, agitation, anxiety,
hostility absent or unvarying;
irritability
Suicidality/Homicidality
Thoughts, behaviors, stated
intent, risks to self or others
Attitude/Insight/Strengths
Adaptive capacity, strengths &
assets, cooperation, insight,
judgment, motivation for
treatment.
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Name:
MIS#:
Agency:
Prov#:
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
INITIAL ASSESSMENT
MH 533
Revised 8/03
Page 8of
IX. Summary and Diagnosis
A. Diagnostic Summary: (Significant: strengths/weaknesses, observations/descriptions, or list of symptoms.)
B. Admission Diagnosis: (check on Prin and one Sec)
Axis I
Prin
Sec Code
Nomenclature
(Medications cannot be prescribed with a deferred diagnosis)
Sec
Axis II
Prin
Code
Nomenclature
Code
Nomenclature
Code
Nomenclature
Code
Nomenclature
Sec
Code
Nomenclature
Sec
Code
Nomenclature
Code
Nomenclature
Axis III
Code
Code
Code
Axis IV Psychosocial and Environmental Problems which may affect diagnosis, treatment, or prognosis
Primary Problem
Circle as many as apply:
1. primary support group
2. social environment
3. educational
4. occupational
5. Housing
6. Economic
7. access to health care
8. interaction with legal system
9. Other psychologcal/environmental
10. inadequate information
Axis V Current GAF
X Above Diagnosis from
DMH Dual Diagnosis Code
Child and Adolescent Initial Assessment
dated
C. Disposition/Recommendations/Plan:
X. Signatures
Assessor’s Signature Discipline*
*LPHA or PHA student with LPHA co-signature
This Confidential Information is provided to you in accord
with State and Federal Laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil
Code and HIPAA Privacy Standards. Duplication of this
information for further disclosure is prohibited without the
prior written consent of the client/authorized representative
to who it pertains unless otherwise permitted by law.
Date
Co-Signature &Discipline**
**Medicare requires signature of M.D. or licensed Ph.D.
Name:
MIS#:
Agency:
Prov#:
Date
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT INITIAL ASSESSMENT
8
CHILD / ADOLESCENT
SUBSTANCE USE ASSESSMENT
MH 533
Revised 8/03
Clinician to verbally administer to child when drug use is reported by child.
SUBSTANCE
AGE AT
FIRST USE
PAST USE
# OF
# OF TIMES
NEVER 1 YR AGO TIMES IN
IN PAST
DAILY
OR MORE PAST YR.
WK.
AMOUNT USED
PER OCCASION
Caffeine, coffee
Nicotine, cigarettes, chewing toacco
Alcohol, beer, wine
Marijuana
Cocaine or crack
Inhalants (glue, paint, etc.)
Amphetamines (crack, crystal, meth, ice, etc)
Ecstasy, MDMA, GHB, others
Hallucinogens (LSD, mushrooms, peyote, etc)
PCP
Opiates (i.e., heroin/pain meds)
Over the counter medications
Prescription
Other
Context of Use
When
With whom
How obtained
Perceived Benefits of Use
Negative Consequences of Use
School / work
Legal
Family / peer relationships
Attempts to Control Use
Personal Limits
Treatment (specify)
Response to Treatment
Describe interaction of substance use with mental health with DSM diagnostic condition.
Was mental health DMS condition present prior to regular drug/alcohol use?
This Confidential Information is provided to you in
accord with applicable Welfare and Institutions Code
Section. Duplication of this information for further
disclosure is prohibited without the prior written
consent of the patient/authorized representative to
who it pertains unless otherwise permitted by law.
Destruction of this information is required after the
stated purpose of the original request is fulfilled.
Yes
No
Name:
MIS#:
Agency:
Prov#:
Unknown
Los Angeles County - Department of Mental Health
CHILD / ADOLESCENT SUBSTANCE USE ASSESSMENT