THE CENTER FOR DRUG-FREE LIVING, INC.
Brief Behavioral Health Status Exam ( 1091 )
CLIENT NAME:
NUMBER:
Start Time:
Purpose of Exam:
Setting:
Evaluate Clinical Necessity
Residential
Outpatient
APPEARANCE:
Looks Stated Age:
Clean
Yes
EYE CONTACT:
Appropriate
ORIENTATION:
MEMORY:
End Time:
X 4:
Neat
No
Detox
Unkempt
Disheveled
Younger
Older
Place
Deficient:
Person
Immediate
ATTENTION:
Adequate
Inadequate
PERCEPTION:
Adequate
Inadequate
MOTOR ACTIVITY:
Normal
COGNITIVE PERFORMANCE:
Other:
Other:
Inappropriate
Time
Normal Limits
Other:
Evaluate Service Needs
Slowed
Restless
Situation
Recent
Remote
Agitated
Normal Limits
Poor memory
Low self-awareness
Short attention
Developmental disability
Poor concentration
Impaired judgement
Slow processing
THOUGHT PROCESS:
Normal limits
Illogical
Delusional
Hallucinating (visual, auditory, tactile)
Paranoid
Ruminative
Intact
Derailed thinking
Loose association
Anti-psychotic medication
DANGER TO OTHERS:
Does not appear dangerous to others
Violent temper
Threatens others
Physical abuser
Hostile
Assaultive
Homicidal ideation
Homicidal threats
Homicide attempt
DANGER TO SELF:
Does not appear dangerous to self
Suicidal ideation
Current plan/means
Recent attempt
Past attempt
Self-injury
Self-mutilation
SENSORY DEFICITS:
None
or
Speech
Hearing
Vision
THE CENTER FOR DRUG-FREE LIVING, INC.
Brief Behavioral Health Status Exam ( 1091 ) Continued
CLIENT NAME:
SPEECH:
MOOD:
NUMBER:
Clear
Minimal
Euthymic
Labile
AFFECT:
Slurring
Incoherent
Slowed
Other:
Unremarkable
Other:
Full range
Depressed
Constricted range
INSIGHT INTO PROBLEM:
Loud
Tearful
Pressured
Anxious
Excessive
Manic
Flat
Takes responsibility
Slight awareness
BEHAVIOR DURING INTERVIEW:
Soft
Cooperative
Oppositional
Other:
Intellectual insight
Blames others
Guarded
Hostile
Emotional insight
Complete denial
Withdrawn
Passive
Acting Out
ADDITIONAL OBSERVATIONS:
CLIENT STRENGTHS:
SERVICE NEEDS:
PROVISIONAL IMPRESSION/DIAGNOSIS:
PLAN OF TREATMENT:
303.90 Alcohol Dependence
311.00 Depressive Disorder NOS
Individual Therapy
Family Therapy
Group Therapy
Psychiatric Referral
DISCHARGE CRITERIA:
Clinician Signature: ____________________________________________ Date: _________
If Medicaid client: LPHA, M. CAP Signature: ________________________Date: _________
Revised 3/05 HRB