Date of Service:
Cost Center/Program:
Direct:
Clinician’s Name & License:
Total:
Code:
Client Identifier:
Consumer’s Name:
Date of Birth:
Guardian’s Name:
Gender:
Guardian’s Phone:
Address:
City:
Ethnicity:
Preferred Language:
Is interpreter needed?
Travel:
Yes No
Zip:
Phone Number:
Provider speaks preferred language:
Yes No
Consumer accepts offer of interpretive services:
Yes No
Youth Link:
Yes No
Probation:
Yes No
Legal Issues/Legal Status:
Education(Highest Grade Completed):
Current School:
IEP
Suspended
Expelled
Veteran
Employment Status:
CalWorks
Provider Preference (gender, location, culture, etc.):
Advance Directive Information Offered (Adults Only)
Medi-Cal Handbook Provided
DESCRIBE HOW YOU WELCOMED THE CONSUMER INTO SERVICE:
WHAT IS THE MOST IMPORTANT THING WE CAN DO TO SUPPORT YOU AND YOUR FAMILY TODAY? (in his/her own words):
DESCRIBE A TIME WHEN YOU AND YOUR FAMILY WERE DOING WELL(in his/her own words):
WHAT DO YOU NEED TO LIVE A HAPPY LIFE? (in his/her own words):
ISSUES/AREAS OF FOCUS:
(in his/her own words)
ARE THERE CO-OCCURRING ISSUES:
Stage of Change:
1.
<select one from below>
2.
<select one from below>
3.
<select one from below>
Clinician’s Signature / License
Clinician’s Name & License Printed
CLINICAL MENTAL HEALTH ASSESSMENT PAGE 1 OF 5
FRESNO COUNTY MENTAL HEALTH PLAN
Yes No
Date
Consumer’s Name:
Client Identifier:
MRTF eform rev 4-12-2010
WHAT STRENGTHS AND RESOURCES DO YOU AND YOUR FAMILY HAVE IN THE CURRENT SITUATION?
SPIRITUAL AND CULTURAL PRACTICES:
FAMILY HISTORY: (If “yes” to any of the following, please explain in description section.)
No significant information.
ETOH abuse/dependence
Suicide attempt
Domestic violence
Divorce
Drug abuse/dependence
Mood disorder
Emotional abuse
Physical/Sexual abuse
Life threatening disease
Death
Other:
Description of Family History:
DESCRIPTION OF CONSUMER/FAMILY RELATIONSHIPS:
Bio Mother
Step Parent
Foster Parent
Bio Father
Siblings
Significant Other
Accepting/Supportive:
Avoidant or Infrequent Contact:
Hostile/Absent:
Living Arrangement:
Number of dependent children (if consumer is an adult):
Number of dependent adults:
Description of family relationships and living situation:
DEVELOPMENTAL HISTORY: (Include prenatal, perinatal, milestones, drug exposure, abuse, premature birth history, ect.)
Describe:
No information available. Explain:
SUBSTANCE USE (consumer and/or family):
Caffeine
Use/abuse issues:
Yes
No
Abuse
Substance abuse in family:
Yes
No
Describe (age of onset, drug of choice, last use, periods of sobriety):
Clinician’s Signature / License
Clinician’s Name & License Printed
CLINICAL MENTAL HEALTH ASSESSMENT PAGE 2 OF 5
FRESNO COUNTY MENTAL HEALTH PLAN
Tobacco
Alcohol
Illegal Drugs
Dependence
Recovery
Denies
Rx Drugs
Date
Consumer’s Name:
Client Identifier:
MRTF eform rev 4-12-2010
TREATMENT HISTORY (Please check all that apply):
None
Self-Help Group Support
Inpatient Substance TX
Psychiatric Hospitalization
Outpatient Substance TX
Other:
Psychotropic Medication Management
Outpatient Psychotherapy
Describe:
CURRENT PSYCHIATRIC & GENERAL HEALTH MEDICATIONS
Name of Medication
Current Dosage/Frequency
Clinician’s Signature / License
Clinician’s Name & License Printed
CLINICAL MENTAL HEALTH ASSESSMENT PAGE 3 OF 5
FRESNO COUNTY MENTAL HEALTH PLAN
None
Prescribing MD
Start Date
Date
Consumer’s Name:
Client Identifier:
MRTF eform rev 4-12-2010
Please use the following scale to rate the individual’s current problem severity for each domain & record duration (optional), in months or
years. Check all adjectives that apply. For ages 0-36 months replace with IFMH ADDENDUM. Use substance use/abuse addendums as needed.
0
No Problem
1
Less than Slight
AFFECT __
2
Slight
Problem
3
Slight to
Moderate
4
Moderate
Problem
__
ANXIETY __
Appropriate
Normal Range
Other
Labile
Constricted
DEPRESSION __
5
Moderate to Severe
Expansive
Blunted
__
6
Severe
Problem
7
Severe to
Extreme
8
Extreme Problem
__
Calm
Phobic
Obsessions
Other:
Anxious/Tense
Worried/Fearful
Compulsions
THOUGHT PROCESS
Guilt
Panic
Anti-anxiety meds.
Anti-psychotic Rx
Appropriate
Sad/Depressed
Irritable
Hopeless
Withdrawn
Grief
Sleep Problems
Lacks Energy/Interest
Appetite Disturbance
Intact
Illogical
Loose Associations
Oriented
Delusional
Ruminative
Circumstantial
Paranoid
Disoriented
Angry
Other:
Guilt
Anti-Depressants
Dissociative State
Other:
Tangential
Hallucinations
Disorganized
HYPERACTIVITY__
Relaxed
Sleep Deficit
Pressured Speech
ADHD Meds
Other:
_
COGNITIVE PROCESS
Inattentive
Manic
Overactive/Hyperactive
Emotional Numbness
History of Abuse:
Emotional
Sexual
Physical
Witnessing/ being victim of crime, severe accident, or natural disaster
Other:
RELATIONSHIPS_
_
Adequate Social Skills
Supportive Relationships
Marital Problems
Negative Peer Influence
Relatedness toward Examiner:
Poor Social Skills
Egocentricity
Problems w/Friends
Overly Shy
Relationship problems at work
Difficulty Establish/Maintain Relationships
SCHOOL
Regular Attendance
Absenteeism
Poor Performance
Expelled/Terminated
Employed
Permanent Disability:
Insightful
Irrational
MEDICAL/PHYSICAL
Good Health
Stress-Related Illness
Somatization
Rx Non-Compliance
_
Acute Illness
Pregnant
Eating Disorder
Seizures
Medical Tx Non-Compliance
Other
Medical Condition:
Impaired Judgment
Concrete Thinking
_
Tardiness
Disruptive
Dropped Out
Illiterate
Not Employed
BEHAVIOR AT HOME _
Within cultural norms
Uncommunicative
Dominating
Tantrums
SOCIO-LEGAL__
Suspended
Defies Authority
Learning Disabilities
Employed Part-time
Seeking Employment
Other:
DANGER TO SELF
_
Doesn’t Appear Dangerous to Self
Denies
Suicidal Ideation
Past Attempt
Serious Self-Neglect
Past Ideation
Recent Attempt
Self-Mutilation
Current Plan
Self-Injury
Inability to Care for Self
Last Hospitalization Date:
Last attempt date:
Other:
Clinician’s Signature / License
Clinician’s Name & License Printed
CLINICAL MENTAL HEALTH ASSESSMENT PAGE 4 OF 5
FRESNO COUNTY MENTAL HEALTH PLAN
Chronic Illness
Hypochondria
Poor Nutrition
CNS Disorder
Other:
Calm
Uncooperative
Belligerent
Runs Away
Oppositional
Sexualized
Other:
Other:
WORK
Poor Attention/Concentration
Developmental Disability
Slow Processing
Poor Memory:
Other:
TRAUMATIC STRESS
Acute
Hyper vigilance
Chronic
Dreams/Nightmares
Detached
Repression/Amnesia
Avoidance
Agitated
Mood Swings
Impulsivity
Intrusive
Disregards Rules
Threatening
Inappropriate
__
Disregards Rules
Lying
Fire setting
Initiates Fights
Offense/Property
Offense/Person
Street Gang
CPS Involvement
Member
Detention/Incarceration Hx:
Last Incarceration Date:
Stealing
Pending Charges
Probation/Parole
Restraining Order
Other:
DANGER TO OTHERS
Doesn’t Appear Dangerous
Threatens Others
Violent Temper
Homicidal Ideation
to Others
Cruelty to Animals
Assaultive
Homicidal Threats
Accused of Child Abuse
Denies
Domestically
Violent
Use of Weapons
Homicidal Attempt
Accused of Sexual Assault
Other:
Date
Consumer’s Name:
Client Identifier:
MRTF eform rev 4-12-2010
CLINICAL SUMMARY/ PRESENTING MENTAL HEALTH PROBLEM:
MEDICAL NECESSITY -- Check all that demonstrate medical necessity for mental health services.
Significant Impairment
Probability of significant deterioration
No Medical Necessity NOA-A issued
Probable developmental arrest
CONSUMER IS IMPAIRED IN THE FOLLOWING AREAS:
Living Arrangement
Employment
Daily Activities
Social Relationships
Health
Describe clinical impairment in above areas :
Is mental health treatment needed?
Yes
No
Prognosis:
General Medical Condition Concerns:
Identify:
Yes
No
Allergies:
Identify:
Good
No
Fair
Poor
Yes
Primary Care Physician:
Phone:
DSM DIAGNOSIS (Must complete all Axes using most current version of DSM codes.)
Axis I
list any secondary substance use Dx on Axis I
Axis II
Axis III
Axis IV
(Psychosocial stressors including co-occurring disorders in the family and homelessness)
Axis V
Current
Clinician’s Signature / License
Clinician’s Name & License Printed
CLINICAL MENTAL HEALTH ASSESSMENT PAGE 5 OF 5
FRESNO COUNTY MENTAL HEALTH PLAN
Past Year
Date
Consumer’s Name:
Client Identifier:
MRTF eform rev 4-12-2010