Individual Name:
DOB:
COMPREHENSIVE CLINICAL ASSESSMENT
Date:
MED ID#
Record #:
Time:
DIAGNOSTIC ASSSESSMENT
Duration:
Location:
Location: 1-other agency, 2-home/residence, 3-jail/prison, 4-shelter/street, 5-PAMH office, 6 - other (specify) II
Information:
Address:
Phone:
City:
State:
County:
Zip:
DOB:
Age:
Race:
Marital Status:
Legal Guardian:
Relationship:
Telephone:
Emergency Contact:
Relationship:
Telephone:
Probation Officer:
County:
Telephone:
Therapist:
Agency:
Telephone:
Med Management:
Agency:
Telephone:
Case Management:
Agency:
Telephone:
Social Worker:
County:
Telephone:
Primary Care Physician:
Telephone:
Chief Complaint/ Presenting Problem(s)/Precipitating event(s)/ Stressor(s):
(must include source of distress, precipitating events, associated problems or symptoms, recent progressions)
Depression/hopelessness
Partner violence/abuse
Eating problems/disorders
Family issues
Anger/irritability
Sexuality/intimacy concerns
Relationship issues
Sexual abuse/rape
Suicidal thoughts/attempts
Legal issues/probation
Divorce adjustment
recent hospitalization
Alcohol/drug use
Anxiety/worry
Parent/child conflict
Job problems/unemployment
Loss/grief
Major life changes
Comments on Presenting Problem(s)/Precipitating event(s)/ Source of Distress/ Recent Progression(s):
1
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Presenting Problem(s) Review:
SELF HARM/
SUICIDAL IDEATION
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
SELF HARM/
SUICIDAL INTENT
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
SELF HARM/
SUICIDAL PLAN
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
SELF HARM/
SUICIDAL MEANS
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
IF MEANS-WHAT:
ACCESS TO GUN(S)
ACCESS TO WEAPON(S)
OTHER
SELF HARM/
SUICIDAL ATTEMPTS
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
DATES:
INABILITY TO CARE
FOR SELF
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
AGGRESSION/
HOMICIDAL
IDEATION
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
AGGRESSION/
HOMICIDAL INTENT
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
AGGRESSION/
HOMICIDAL PLAN
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
EXPLAIN:
AGGRESSION/
HOMICIDAL MEANS
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
IF MEANS-WHAT:
ACCESS TO GUN(S)
ACCESS TO WEAPON(S)
OTHER
INTENDED VICTIM:
2
REVISED 7/29/14
Individual Name:
AGGRESSION/
HOMICIDAL
ATTEMPTS
DOB:
MED ID#
Record #:
NONE
CURRENT
PAST
INTERMITTENT
CONSTANT
Other
Symptoms/Issues:
DATES:
Description:
DEPRESSION
Symptoms
None
sadness
Hopelessness/ Helpless
Fatigue/ Loss of energy
psychomotor agitation/retardation
Increased/Decreased sleep
Increased/Deceased appetite
Loss of interest/pleasure in activities
Feelings of worthlessness or inappropriate guilt
Suicidal ideation, attempts/plans or excessive
thoughts of death
Decreased concentration
Anhedonia
Weigh loss/gain
Self abuse
crying spells
Other:
Explain:
ANGER
Symptoms
None
irritability
Explain:
ANXIETY
Symptoms
None
Excessive anxiety/worry
Restlessness or feeling keyed up or on edge/nervousness
Easily
fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep
disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep, nightmares)
Panic
attacks
Dissociation
Phobias
Obsessive thinking
Compulsive behaviors Social Phobia
Flashbacks
Psychosomatic complaints Soiling Separation Anxiety
Other:
Explain:
ORGANIC
Symptoms
None
Unmanageable
Confusion
Other:
Explain:
MANIA
Symptoms
None
Elevated mood Irritability Pressured Speech
Euphoria Over-talkative Decreased need
for sleep Flight of Ideas Distractibility Increased goal-directed activity Psychomotor agitation
Increased spending Increased risk taking behaviors
Increased libido promiscuity
grandiosity racing thoughts
Other:
Explain:
PSYCHOTIC
Symptoms
None
Hallucinations
Delusions
Paranoia
Loose Associations
Disorganized Behavior
Catatonic Behavior
Negative symptoms (flat affect, alogia [lack of speech] or avolition [lack of
drive, motivation or desire to pursue meaningful goals]) Social Withdrawal
Disorganized speech
Catatonia Poverty of speech Anhedonia Suspiciousness Poor judgment
Disorientation
Other:
Explain:
destructive
aggressive
Inability to care for self
self abusive
homicidal
Memory deficits
other
Wanders off
Forgetfulness
3
REVISED 7/29/14
Individual Name:
DOB:
MED ID#
Record #:
Interpersonal
Issues
None
Conflict
Enmeshment
Isolation/avoidance
Emotional disengagement
Poor social skills
Relationship issues
Poor boundaries
Problems at work
Difficulties establishing/maintaining
relationships
Lack of a positive support system
Egocentricity
Other:
Explain:
Eating
None
Increase
Other:
Explain:
Oppositional
Defiance/Conduct
None
Disregards Rules/Authority
Defiant
Stealing
Lying
Initiates fights/Arguments Destroys
property Cruelty to animals Sexually inappropriate Fire setting
Easily annoyed Angry
Resentful Vindictive Loses Temper
Argumentative Annoys others
Blames others
Other:
Explain:
LEGAL
None
Past or Present Legal Issues?
No
Yes
Arrests/Incarceration
No
Yes
Currently on Probation?
No
Yes
Involved in juvenile Justice Department?
No
Pending issues with Legal System No
Yes
Decrease
Restrictive
Binging
Purging
Body Image
Yes
Explain:
SLEEP
None
Hyper-somnia
Other:
Explain:
Insomnia
TRAUMA
Symptoms
None
Acute
Chronic
Hypervigilance
Emotional numbness
Other:
Explain:
Inattention/
Hyperactivity
None
Makes careless mistakes
has trouble keeping attention on tasks
does not follow through or
finish tasks
has trouble organizing activities.
loses things needed for tasks and activities
easily distracted
forgetful in daily activities
Often avoids, dislikes, or doesn't want to do
things that take a lot of mental effort
fidgets with hands or feet or squirms in seat
has trouble
playing or doing leisure activities quietly
Is often "on the go" or often acts as if "driven by a motor".
Talks excessively
blurts out answers before questions have been finished.
Has trouble waiting
one's turn.
interrupts or intrudes on others
Impulsivity
Personality Traits
CLUSTER A
None
Paranoid features
Explain:
Schizoid
Disrupted
Nightmares
Dreams/nightmares
Schizotypical
Reduced need for sleep
Disassociation
Other:
4
REVISED 7/29/14
Individual Name:
Personality Traits
CLUSTER B
DOB:
None
* Borderline
Explain:
MED ID#
Record #:
Antisocial
Narcissistic
Histrionic
Other:
*Borderline Traits:
Excessive fear of abandonment
Unstable and intense relationships
Idealization / devaluation
Identity disturbance
Impulsivity
Recurrent suicidal behavior
Affective instability
Inappropriate
Intense anger Transient paranoid ideation
Disassociation
Personality Traits
None
Avoidant
Explain:
Dependent
Obsessive –Compulsive
Personality not otherwise specified
Pervasive
Developmental
Disorder History
None
Explain:
Pregnancy/
Developmental
history
None
No info
No problems
Premature Birth
Use of substances/alcohol during pregnancy
Problems during prenatal/ natal/ postnatal
Reached appropriate developmental millstones
Did not Reach appropriate developmental millstones
Other:
Explain:
CLUSTER C
Psychosocial Assessment
Strengths/Abilities:
Preferences:
Weakness:
Challenge/Risk(s):
Natural & Informal Supports: (include strengths & challenges)
Current Living Situation: (include any environmental challenges or strengths related to the individuals living situation)
Family Relationships: (include strengths & challenges)
Social/Peer Group: (include strengths & challenges)
Significant Social, Ethnic, Cultural or Language Factors:
5
REVISED 7/29/14
Other:
Individual Name:
DOB:
MED ID#
Record #:
Leisure Activities/Hobbies/Recreation:
Spiritual/Religious Preferences:
Military Service History:
No
Yes
If yes, please explain:
Is the individual employed?
No
Yes If no, does the individual wish to be employed?
No
Yes
Please include a brief employment history (primary type of work done, long term or short term employment, hx of termination, etc.):
Highest Level of Education Completed:
Current Educational Needs:
Significant Childhood History: Early Childhood
Happy one
Unhappy one
Adopted
Other:
Explain:
Past History of Physical or Sexual Abuse or Neglect?
No
Yes
If yes, please explain:
Additional Comments:
6
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Psychiatric/Behavioral History
Past psychiatric hospitalizations?
Yes
No
Yes
No
If yes, please list dates and locations:
ECT or other specialized treatment
If yes, please explain:
Was there improvement?
Attitude about treatment
Yes
No Treatment Response
Unknown
Poor
Fair
Unknown
Improved
Worse
No Change
Good
What contributed or inhibited improvement?
Medications helped, but did not continue treatment.
Previous psychiatric/ outpatient services?
Yes
Yes
No
No
If yes, please provide names of providers, types of services received and dates attended if possible:
Outpatient Therapy Services:
Medication Management:
Community Support Team:
Intensive In Home Services:
Multi Systemic Therapy:
Day Treatment:
Partial Hospitalization:
Targeted Case Management:
Therapeutic Foster Care:
Residential Treatment Level II, III or IV:
Psychiatric Residential Therapeutic Facility (PRTF):
Jail/Detention:
Other:
Was there improvement?
Change
Attitude about treatment
Yes
Unknown
No
Treatment Response
Poor
Fair
Unknown
Improved
Worse
No
Good
What contributed or inhibited improvement?
7
REVISED 7/29/14
Individual Name:
DOB:
MED ID#
Record #:
Please describe any additional psychological strengths or challenges:
Family history: mental illness?
Yes
No
History of alcohol /substance misuse
Yes
No
If yes, please give brief description:
Medical History (Does the individual report any of the following? Check all that apply and describe below.):
Head injury/stroke
Thyroid problems
Chronic pain:
STD:
Hypertension
HIV/AIDES
Hepatitis
Asthma
Kidney disease
Diabetes
Liver disease
Seizures
COPD
Sleep disturbances
Adverse reaction to meds
Other:
Pregnancy
Appetite changes
Weight changes
Other
Comments on Medical History:
Surgeries:
None
N/A
Allergies:
None
N/A
Disability (hearing impairment, visual impairment, mobility):
Current Medications:
None
Medication
None
N/A
N/A
Dosage
Frequency
Effective
Side Effects
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Comments on Medications:
8
REVISED 7/29/14
Individual Name:
Past Medications:
DOB:
MED ID#
Record #:
None
Medication
Dosage
Frequency
Effective
Side Effects
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Comments on Medications:
Substance Abuse Evaluation
None
Do you drink and or use drugs? -
Yes
No
C-
Yes
No Have you ever felt the need to Cut down on your drinking/drug use?
A-
Yes
No Do you get Annoyed at criticism by others about your drinking/drug use?
G- Yes
No Have you ever felt Guilty about drinking/drug use or something you have done
while drinking/using drugs?
E-
Yes
No Eye-opener: Have you ever felt the need for a drink early in the morning?
Treatment History including outpatient, court ordered, and admission for Detox (AA/NA
EXPLAIN:
9
REVISED 7/29/14
Individual Name:
DOB:
MED ID#
Record #:
Note: Must Complete A and B
OTHER
SEDATIVES
PCP
INHALANTS
OPIOIDS
HALLIUCINOGEN
COCAINE
ALCOHOL
None
CANNABIS
CHECKLIST FOR DEPENDENCY DETERMINATION
AMPHETEMINES
SUBSTANCE ABUSE ASSESSMENT A
AT LEAST 3 OF THE FOLLOWING CRITERIA
1.
Tolerance
2.
Withdrawal
3.
Loss of control using more than intended
4.
Unsuccessful attempts to control use
5.
Excessive time involved in acquiring and
using drugs
6.
Lifestyle change due to use
7.
Using, knowing it causes other problems
Duration (3 or more criteria in 12 months)
Criteria Met:
1.
With physiological dependence
2.
Without physiological dependence
CHECKLIST FOR ABUSE DETERMINATION
At least one of the following 4 criteria:
1.
Use interferes with responsibilities
2.
Use interferes with safety
3.
Use causes legal problems
4.
Use causes social and interpersonal
problems
Duration: 1 OR MORE CRITERIA IN THE SAME 12
MONTH PERIOD)
FAILSTO MEET CRITERIA FOR DEPENDENCE FOR
THIS SUBSTANCE
ABUSE CRITERIA MET
10
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
COMMENTS:
SUBSTANCE ABUSE ASSESSMENT B
Substance Abuse Evaluation
Chemical
None
Age at
first use
Age of
regular
use
Date of
last use
Amount
Frequency
ROA
Current Use
Yes or No
Alcohol
Amphetamine
Methamphetamine
Cocaine/Crack
Marijuana
Heroin
Opiates pain
medications
Hallucinogens
Benzodiazepines
Sedatives or
sleeping Pills
Inhalants
Nicotine
Other
COMMENTS:
11
REVISED 7/29/14
Individual Name:
DOB:
MED ID#
Record #:
Mental Status
(Do Not Leave Explanation Blank)
Affect
Motor
Activity/Speech
Thought
Appearance
Attitude/behavior
Orientation
Constricted
Other:
Explain:
Flat
Labile
Impulsive
Poor Concentration/Attention
Denial
Self-blame
Blaming others
Insight
Poor Concentration
Impaired Decision Making
Disoriented
Thoughts
Other:
Explain:
Neat
Disheveled
Explain: (description)
relaxed
eccentric
Attentive
Guarded
Cooperative
Self destructive Hostile tantrums
compulsive behaviors
Explain:
person
Explain:
Average
IQ______
Explain:
Memory
Adequate
IQ______
Explain:
place
time
known disability
Impaired(short term/long term)
Adequate
Explain:
ideas of reference
limited
worried
expressionless
hostile
Demanding
Passive
Dependent
Defensive
dirty manipulative Paranoid negative silly
uncertain
Reported hallucinations frequently
Paranoia
Explain:
Dramatic
Ruminative
Tangential
Illogical
Poor
Slow Processing
Flight of ideas Racing
tearful
sad
dirty
Seductive
Evasive
immature euphoric
situation
suspected below average
Impaired (explain)
triggers _______________________
Auditory_________________________
Judgment/Insight
Dramatic
Low energy
Restlessness/hyperactive Agitated
Inattentive
Pressured Speech
Slow Speech
Disorganized Speech
Other:
Explain:
Intellect
Perceptions
Blunt
forgetfulness
Limited
visual______________________
Delusions_________________________
suspicious
uncertain
Above Average
uncertain
disorganized
depersonalized
inability to accurately predict consequences
impaired(explain):
12
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Diagnostic Impressions:
(please include diagnostic codes)
Diagnosis and Codes
Symptoms of Diagnosis and Explanation of Axis IV that are Checked
Axis I
Primary:
Secondary:
Tertiary:
Axis II
Axis III
Axis IV
Problems with primary support group
Problems related to social environment/school
Educational problems
Occupational problems
Housing problems
Economic problems
Problems accessing health care services
Problems with interactions with legal system
Other:
Axis V
GAF =
13
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Interpretation and Analysis Summary
14
REVISED 7/29/14
Individual Name:
DOB:
MED ID#
Record #:
TREATMENT PLAN
(Please Ensure Treatment Plan is on its Own Page as it Will be Taken Out of the Assessment)
Service(s) Modalities/Intervention
(including frequency and
duration)
Goal
Responsible Person/Position
*All goals will be measured monthly
per 24 consecutive months and
based on consumer guardian, if
applicable, and OPT provider input
Target Date
Reviewed Date
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Status Codes:
R= Revised
O= Ongoing
Status Code
Justification for
Continuation/Discontinuation
of Goal
A= Achieved
D= Discontinued
15
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Treatment Plan Signature Page
Primary Clinician Signature
Date
Client/parent/guardian signature
Date
Clinical Director Signature
Date
Medical Director /Nurse Practitioner / Physician Assistant
Date
16
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Recommendation for services, supports, additional assessments and/or treatment:
Recommended Service(s):
Outpatient Treatment
Residential Level II
Community Support Team
Day Treatment
Intensive In-Home Services
Targeted Case Management
Group Therapy
Medication Management
Assertive Community Treatment Team
Substance Abuse Intensive Outpt Program
SA Comprehensive Outpt Treatment Prog
Multi-Systemic Outpt Treatment Prog
Mobile Crisis Services
Psychosocial Rehabilitation
Other:
Immediate Psychiatric/Medical evaluation
Day Supports
Residential Supports
Respite
Targeted Case Management
Community team meet and update PCP
Updated Psychiatric evaluation
Updated Medication evaluation
Psychological Evaluation
Neuropsychological Evaluation
OT evaluation to rule out sensory integration disorder
Psycho educational testing to rule out learning disability which can occur
Hearing assessment
Team meet with stakeholders to update PCP including the school, DJJ, DSS as indicated
Speech and Language evaluation
Safety plan be developed for community, school (if applicable) and home
Consider DSS support/involvement
Behavioral plan via consultation with therapist
Social skills training, ideally in a group setting via outpatient group therapy
Family therapy
Individual therapy
Referral to outpatient therapy
Referral to PSR
Referral to CAP services
Link with natural supports as identified in the PCP
Sex Offender Risk assessment/SOSE
Evaluate community concern/questions related to sexualized behavior
Consider out-of-home placement via Medicaid approved service
Therapeutic Foster Care
Vocational Rehab (VR) Referral
Substance Abuse Services:
Residential:
Clinically recommended target population eligibility:
CMSED
CMMED
CMDEF
CMECD
CSSP
CSDWI
CSWOM
CSCJO
AMSPM
ASDSS
AMSWI
ASDWI
AMPAT
ASMHT
AMDEF
ASCJO
CMPAT
CSMAJ
AMSRE
ASDHH
CSSAD
CSDN
CSIP
CDECI?
ASCDR
ASHOM
ASWOM
ADMRI
(include referrals to agencies, additional services, and further evaluation and testing
recommendations):____________________________________________________________________________________________________
17
REVISED 7/29/14
Individual Name:
DOB:
Record #:
MED ID#
Assessment Signature Page
Primary Clinician Signature
Date
Client/parent/guardian signature
Date
Clinical Director Signature
Date
Medical Director /Nurse Practioner / Physician Assistant
Date
18
REVISED 7/29/14