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PSYCHOSOCIAL ASSESSMENT
Procedure Code:
H0031
Service Date:
(Date of Face-to-Face)
Start Time:
Stop Time:
(This assessment is due within 14 days of the date of the intake. This assessment must be completed prior to, or at the time of, the
individual's person centered planning meeting development of the IPOS.)
I.
PRESENTING PROBLEM (reason why individual is seeking services)
Past Psychiatric/Psychological History: (including past medications)
Current Medications, including psychotropic, over-the-counter, herbal remedies
Current Medications
(include all meds taken over past 6 months)
Frequency
Prescribed By
Dosage
Is individual compliant with medications?
Yes
No
Reason for prescription
If no, please explain:
Allergies:
Past medical history (include hospitalizations, surgeries, physical limitations):
Family/social history (including minor children, associated needs and risk factors):
Current and past employment history (include past trainings):
Education (include highest grade completed, schools attended, special education, discipline problems, etc.):
Current Legal Status:
Parole
II.
Probation
No legal involvement
Charges pending
Previous jail
Has guardian
DRUG/ALCOHOL ASSESSMENT
SUBSTANCE USE HISTORY
(Include experimentation & accidental ingestion. Include alcohol, tobacco, and caffeine)
Age
Age
# days
Amount
1st
Last
Onset of
Amount used
Method
1st
last
used in last used in last as
used
heavy use
daily/weekly
used used
30
48 hrs.
RX? when?
Drug
Drug of
choice
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 1 of 7
Medicaid Number:
Address Here
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PSYCHOSOCIAL ASSESSMENT
SUBSTANCE USE HISTORY
(Include experimentation & accidental ingestion. Include alcohol, tobacco, and caffeine)
Age
Age
# days
Amount
1st
Last
Onset of
Amount used
Method
1st
last
used in last used in last as
used
heavy use
daily/weekly
used used
30
48 hrs.
RX? when?
Drug
Any changes in patterns of use over time?
No
Drug of
choice
Yes
Does individual ever drink or drug more than he/she intends?
No
Yes
Has individual experienced an increase in the amount he/she can use to get the same effect?
Is there a history of overdose?
No
Yes, describe:
Is there a history of seizures?
No
Yes, describe:
Is there a history of blackouts?
No
Yes, describe:
Has individual ever used medications to either get high or come down from being high?
No
No
Yes
Yes
With whom does individual usually use?
Has individual had previous substance abuse treatment?
No
Yes, where:
Assessment of risk in this area:
III. MENTAL STATUS ASSESSMENT (Describe any deviation from the norm under each category.)
Appearance
Mood
Well groomed
Disheveled
Bizarre
Other:
Normal
Depressed
Anxious
Euphoric
Irritable
Other:
Describe:
Describe:
Attitude
Speech
Cooperative
Uncooperative
Suspicious
Guarded
Belligerent/Hostile
Other:
Describe:
Normal
Soft
Loud
Pressured
Halting
Incoherent
Slurred
Nonverbal
Limited communication skills
Uses yes/no only
Uses a picture board
Other:
Describe:
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 2 of 7
Medicaid Number:
Address Here
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PSYCHOSOCIAL ASSESSMENT
Motor Activity
Thought Process
Calm
Hyperactive
Agitated
Other:
Tremor/Tics
Lethargic
Describe:
Intact
Tangential
Circumstantial
Loose Associations
Other:
Flight of ideas
Concrete thinking
Inability to abstract
Can only follow 1- step directions
Describe:
Affect
Thought Content
Appropriate
Sad
Flat
Anxious
Other:
Inappropriate
Angry
Constricted
Labile
Describe:
Normal
Morbid
Somatic Complaints
Aggressive
Other:
Paranoid
Phobias
Obsessive
Describe:
Orientation:
Psychosis:
Person
Place
Time
Responds to name
Recognizes familiar faces or places
Knows own daily schedule
N/A
Describe:
Describe:
Hallucinations:
Denies
Auditory
Visual
Other:
Command Hallucinations:
Denies
Harm to self
Harm to others
Can resist commands
Other:
Describe:
Describe:
Bizarre Delusions:
Denies
Thought Broadcasting
Thought Insertion
Thought Withdrawal
Other:
Delusional Beliefs:
Denies
Religious
Somatic
Persecutory
Grandiosity
Being controlled
Ideas of reference
Describe:
Describe:
Summary/Assessment of Mental Status Exam:
IV.
HEALTH AND SAFETY (Assess as if person served were not in current placement.)
Identified Risk Factors:
None
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 3 of 7
Medicaid Number:
Address Here
Logo Here
PSYCHOSOCIAL ASSESSMENT
Unsafe Sex Practices
Pregnancy
Sexual Abuse
Alcohol/Substance Abuse
Self Harm
Aggression Toward Others
Verbal/Emotional Abuse
Children at Risk
Evacuation Score:
Other:
Physical Abuse
Residential Safety
IV Drug Abuse
Diet/Nutrition
Nicotine Use
Medication Interaction
Medication Management
Stress Related to Parenting
None
Quarterly TD Screening - Due:
Vision Exam
Assistance With Children’s Needs
Other:
Impulsivity
Chronic Health Problems
Non-Attentive to Need for Health Care
Hygiene
Household Management
Physical Disability
Recent Loss (Parent, child, spouse, job, relationship)
Psychosis
Community Safety
Identified Needs:
Able to meet basic needs?
Food
Nutrition Assessment
Labs - Frequency:
Health Care Assessment/Yearly Checkup
Dental Exam
Coordination of Care
N/A
Medical
Shelter
Describe:
DANGEROUSNESS
A. Suicide Risk
None
Describe History of Suicidality:
Ideation
Chronic
Acute
Recent suicidal behavior
Presence of Risk Behavior:
Yes
Yes
Yes
Yes
No
No
No
No
Note
Will
Gives possessions away
Other:
Yes
Yes
Yes
None
No
No
No
Describe:
Presence of Risk Factors:
Intent
Means to carry out plan
Access to gun
None
Prior attempts
Lethality
Plan
Likelihood of rescue
Describe:
B. Threat of Danger to Others
Thoughts of harm to others?
Identified target
Means to carry out plan
Prior aggression
None
Yes
Intent
Lethality
Plan
No
Recent threatening behavior?
Yes
No
Can thoughts of harm be managed
Access to gun
Describe:
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 4 of 7
Medicaid Number:
Address Here
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PSYCHOSOCIAL ASSESSMENT
C. Presence of Other High Risk Behaviors:
Cutting
Anorexia/Bulimia
Other:
None
Head banging
Risk taking
Poor or dangerous relationship
Other self-injurious behavior
Describe:
D. Presence of Deterrents:
N/A
Describe:
E. Other Safety Concerns:
None
Describe:
F. Assessment of Risk:
V.
FUNCTIONAL SUMMARY (Clinician’s view; check column as applicable)
Not
Applicable
Function
Strength
Concern
Function
Daily Activities
Safety
Family relationships
Legal
Social Relationships
Cognitive
Functioning
School
Housing
Work
Social Skills
Finances
Impulse Control
Physical Health
Responsibility
VI.
VII.
Not
Applicable
Strength
Concern
SUMMARY OF STRENGTHS, ABILITIES, NEEDS, & PREFERENCES (Clinician’s view with client’s input)
OBSTACLES/BARRIERS TO SUCCESSFUL OUTCOMES
VIII. DIAGNOSTIC INFORMATION (codes & nomenclature)
*Designate “P” for primary diagnosis
Code
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 5 of 7
Medicaid Number:
Address Here
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PSYCHOSOCIAL ASSESSMENT
Code
*Axis I
Code
Code
Code
Axis II
Code
Code
Axis III
Code
Code
Axis IV
(Check all that are appropriate and specify the problem
Problems with primary support group
Specify:
Problems related to the social environment
Specify:
Educational problems
Specify:
Occupational problems
Specify:
Housing problems
Specify:
Economic problems
Specify:
Problems with access to health care services
Specify:
Problems related to interaction with the legal system / crime
Specify:
Other psychosocial & environmental problems
Specify:
None
Axis V
OUTCOMES:
GAF/GAS:
CAFAS:
Multnomah:
IX.
TREATMENT/SERVICES/SUPPORTS RECOMMENDATIONS FOR CLIENT/FAMILY
(Add a bold letter from the list below to each checklist item (rather than a checkmark) to indicate activity required).
Link
Coordinate
Provide
Psychiatric Consultation
Psychological Evaluation
Speech/Language
Occupational Therapy
Physical Therapy
Group Home/AFC
Assistance with Benefits
Physical Health Assessment
Dept. of Human Services (formerly FIA)
Train
Monitor
Instruct
Community Support
Medication Assistance
Nursing Support
Housekeeping
Family Education
Employment Assistance
Money Management
Dietary/Nutrition
Assess
Refer
ADvocate
Individual Therapy
Group Therapy
Family Therapy
Dual Diagnosis Group
Social Activity/Recreation
Housing Assistance
ADL Instruction
Transportation
Community Action
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 6 of 7
Medicaid Number:
Address Here
Logo Here
PSYCHOSOCIAL ASSESSMENT
Social Security Administration
Home Health
Room and Board
Primary Health Care
MRS/MI Jobs Commission
CLF
Substance Abuse Assessment
Other (see Medicaid Chapter III / State Plan):
Initial Completion:
Clinician/Credentials
Date:
Supervisor/Credentials
Date:
Client Name:
DOB:
Section 4
Staff Name:
Last revised: April 24, 2008
Case Number:
Page 7 of 7
Medicaid Number: