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Start Time:
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Stop Time:
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PRESENTING PROBLEM
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Past Psychiatric/Psychological History
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Is individual compliant with medications?
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If no, please explain:
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Past medical history
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Family/social history
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Current and past employment history
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Education Details
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Current Legal Status:
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DRUG/ALCOHOL ASSESSMENT
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SUBSTANCE USE HISTORY
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Drug
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Method
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Age 1st used
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Age last used
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Onset of heavy use
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# days used in last 30
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Amount used in last 48 hrs.
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1st as RX?
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Last used when
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Amount used daily/weekly
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Drug of choice
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Drug
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Method
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Age 1st used
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Age last used
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Onset of heavy use
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# days used in last 30
|
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Amount used in last 48 hrs.
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1st as RX?
|
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Last used when
|
Amount used daily/weekly
|
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Drug of choice
|
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Drug
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Method
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Age 1st used
|
Age last used
|
|
Onset of heavy use
|
# days used in last 30
|
|
Amount used in last 48 hrs.
|
1st as RX?
|
|
Last used when
|
Amount used daily/weekly
|
|
Drug of choice
|
|
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Drug
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Method
|
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Age 1st used
|
Age last used
|
|
Onset of heavy use
|
# days used in last 30
|
|
Amount used in last 48 hrs.
|
1st as RX?
|
|
Last used when
|
Amount used daily/weekly
|
|
Drug of choice
|
|
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Drug
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Method
|
|
Age 1st used
|
Age last used
|
|
Onset of heavy use
|
# days used in last 30
|
|
Amount used in last 48 hrs.
|
1st as RX?
|
|
Last used when
|
Amount used daily/weekly
|
|
Drug of choice
|
|
|
Drug
|
Method
|
|
Age 1st used
|
Age last used
|
|
Onset of heavy use
|
# days used in last 30
|
|
Amount used in last 48 hrs.
|
1st as RX?
|
|
Last used when
|
Amount used daily/weekly
|
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Drug of choice
|
|
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Any changes in patterns of use over time?
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Ever drink or drug more than he/she intends?
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Experienced an increase to get the same effect
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Is there a history of overdose?
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If yes, please describe
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Is there a history of seizures?
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If yes, please describe
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Is there a history of blackouts?
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If yes, please describe
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Used medication to get high or come down
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With whom does individual usually use?
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Had previous substance abuse treatment?
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If yes, where
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Assessment of risk in this area:
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MENTAL STATUS ASSESSMENT
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Appearance
• • •
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Other
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Describe
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Mood
• • •
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Other
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Describe
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Attitude
• • •
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Other
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Describe
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Speech
• • •
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Other
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Describe
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Motor Activity
• • •
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Other
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Describe
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Thought Process
• • •
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Other
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Describe
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Affect
• • •
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Other
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Describe
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Thought Content
• • •
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Other
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Describe
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Orientation:
• • •
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Other
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Describe
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Psychosis:
• • •
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Other
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Describe
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Hallucinations:
• • •
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Other
|
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Describe
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Command Hallucinations:
• • •
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Other
|
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Describe
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Bizarre Delusions:
• • •
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Other
|
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Describe
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Delusional Beliefs:
• • •
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Other
|
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Describe
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Summary/Assessment of Mental Status Exam
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HEALTH AND SAFETY
|
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HEALTH AND SAFETY
|
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Psychosocial Assessment
|
|
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Identified Risk Factors:
• • •
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Other
|
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Evacuation Score:
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Quarterly TD Screening - Due:
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Identified Needs:
• • •
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Other
|
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Labs - Frequency:
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Describe
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Able to meet basic needs
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DANGEROUSNESS
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|
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Suicide Risk-None
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Describe History of Suicidality
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Chronic
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Ideation
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Recent suicidal behavior
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Acute
|
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Presence of Risk Behavior- None
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Will
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Note
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Other
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Gives possessions away
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Describe
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Describe
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Presence of Risk Factors:
• • •
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Threat of Danger to Others- None
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Recent threatening behavior
• • •
|
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Thoughts of harm to others
• • •
|
|
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Describe
|
Describe
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Presence of Other High Risk Behaviors
• • •
|
Describe
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Presence of Deterrents: N/A
|
Describe
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Other Safety Concerns: N/A
|
|
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Assessment of Risk:
|
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FUNCTIONAL SUMMARY
|
|
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Daily Activities
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Family relationships
|
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Social Relationships
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School
|
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Work
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Finances
|
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Physical Health
|
Safety
|
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Legal
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Cognitive Functioning
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Housing
|
Social Skills
|
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Impulse Control
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Responsibility
|
|
Summary of strength/ability/need & preference
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OBSTACLES/BARRIERS TO SUCCESSFUL OUTCOMES
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|
DIAGNOSTIC INFORMATION
|
|
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Axis I: Code
|
Axis I: Code
|
|
Axis I: Code
|
Axis I: Code
|
|
Axis II: Code
|
Axis II: Code
|
|
Axis II: Code
|
Axis II: Code
|
|
Axis III: Code
|
Axis III: Code
|
|
Axis III: Code
|
Axis III: Code
|
|
Axis IV
• • •
|
Please specify
|
|
Axis V
|
|
|
OUTCOMES:
|
GAF/GAS:
|
|
CAFAS:
|
Multnomah:
|
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TREATMENT/SERVICES/SUPPORTS RECOMMENDATIONS
|
|
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Psychiatric Consultation
|
Psychological Evaluation
|
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Speech/Language
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Occupational Therapy
|
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Physical Therapy
|
Group Home/AFC
|
|
Assistance with Benefits
|
Community Support
|
|
Medication Assistance
|
Nursing Support
|
|
Housekeeping
|
Family Education
|
|
Employment Assistance
|
Money Management
|
|
Individual Therapy
|
Group Therapy
|
|
Family Therapy
|
Dual Diagnosis Group
|
|
Social Activity/Recreation
|
Housing Assistance
|
|
ADL Instruction
|
Physical Health Assessment
|
|
Dietary/Nutrition
|
Transportation
|
|
Dept. of Human Services (formerly FIA)
|
Community Action
|
|
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
|
|
