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IDENTIFYING INFORMATION
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Patient Sex
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Marital Status
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Patient arrived with
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Accompanied (By Whom)
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Patient Living
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Patient lives with whom explain
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Patient Employment Status
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Patient Living (Sponsor)
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Physical Barriers to Treatment
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Physical Barriers Comments
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Specific Barriers to Treatment
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Specific Barriers Others
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Patient Current Medications
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Medication Instruction
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Patient Other Services
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CURRENT PROVIDERS
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PCP
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Specialists
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Therapists (Self)
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Other
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PAST PSYCHIATRIC HISTORY
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Psychiatric History Includes
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Patient Hospitalized
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Patient Hospitalised Where
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When patient hospitalised
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Hospitalised Medications
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Hospitalised
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CLIENT'S MEDICAL HISTORY
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Medical/Physical Problems
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Any other medical problem
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Patient's Surgical Procedures
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Tests, Labs
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Consultation for substance abuse
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Patient's Dental Provider
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Date of Last Dental Service
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Patient's Disability
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Identify Disability
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Disability Compensation
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Disability Compensation Comments
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PATIENT FAMILY MEDICAL HISTORY
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Family Medical History
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Consultation for medical abuse
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Paternal Family Mem Health Issue
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Consultation for mental health
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PATIENT FAMILY MENTAL HISTORY
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Paternal - Family Member Diagnos
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Paternal - Describe Treatment
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Paternal - Describe Response
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Paternal - Describe Medication
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Paternal family health issue
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Maternal - Family Member Diagnos
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Maternal - Describe Response
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Maternal - Describe Treatment
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Maternal - Describe Medication
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Maternal Family Mem Health Issue
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CLIENT'S DEVELOPMENTAL HISTORY
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Client's Place of Birth
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Moves in Lifetime
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Development
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Development Explain
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Client's Parents Married
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Client Raised by (Parent)
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Client's # of Siblings(Name(s)/A
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Siblings (Name(s) and Age(s)
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Client's Family Contact
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Client's Sexual Status
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Client First Sexual Encounter Ag
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Was this consensual
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Sexual Orientation(s)
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SPIRITUAL HISTORY
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Practice by Family
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Spiritual/Cultural Belief System
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Spiritual/Cultural Comments
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CLIENT'S HISTORY
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Client Marriage History
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Client's Children (names and age
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EDUCATIONAL HISTORY
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Last School Attended
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Learning Disabilities
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Learning Disabilities Comments
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Special Education
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Special Education Comments
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College Training
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College Training Where
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Vocational Schooling
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Vocational Schooling Where
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Special Training
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Special Training Where
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MILITARY SERVICE
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Military Service
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Military Service Branch
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Military Service Active Duty
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Military - Type of Discharge
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Military - Date of Discharge
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VOCATIONAL HISTORY
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Vocational History
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Current Employment
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Current Employment Explain
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Current Employment Duration
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Past Employment
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Past Employment Explain
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Past Employment Duration
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Reason for Leaving
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LEGAL HISTORY (Explain if Necess
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Ever Arrested
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Ever Convicted
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Current Legal Problems
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Physical
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Emotional
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Neglect
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Describe- Nature of Relationship
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Describe - Duration
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Describe - Severity of Abuse
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Ever been in an accident
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Seen someone injured or die
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Die or Injured Comments
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SUBSTANCE USE HISTORY
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Have you ever used tobacco
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Do you use tobacco now
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Tobacco Amount
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Tobacco in what form
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Do you drink alcoholic beverages
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Alcoholic Beverages
• • •
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Alcoholic Beverages Amount
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Do you drink caffeine beverages
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Caffeine Amount Daily
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Treatment for Addiction
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Have you ever used
• • •
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Ever used street drugs
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Ever used prescription Med
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Do you now
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Rate you risk for HIV
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Risk for STD or Hepatitis
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Experienced Problems With
• • •
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Explain Experienced Problems
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SUBSTANCE USE INFORMATION
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Drug - Age at first use
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Drug - Most recent use
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Drug - How often
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Drug - How Admin
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Caffeine - Age at first use
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Caffeine - Most recent use
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Caffeine - How often
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Caffeine - How Admin
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Marijuana - Age at first use
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Marijuana - Most recent use
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Marijuana - How often
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Marijuana - How admin
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Cocaine/Crack - Age at first use
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Cocaine/Crack - Most recent use
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Cocaine/Crack - How often
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Cocaine/Crack - How admin
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Hallucinogen - Age at first use
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Hallucinogen - Most recent use
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Hallucinogen - How often
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Hallucinogen - How admin
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Heroin - Age at first use
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Heroin - Most recent use
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Heroin - How often
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Heroin - How admin
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Opioids - Age at first use
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Opioids - Most recent use
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Opioids - How often
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Opioids - How admin
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Meth - Age at first use
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Meth - Most recent use
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Meth - How often
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Meth - How admin
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Methamphetamines- Age-first use
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Methamphetamines-Most recent use
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Methamphetamines- How often
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Methamphetamines- How admin
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Amphetamines - Age at first use
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Amphetamines - Most recent use
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Amphetamines - How often
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Amphetamines - How admin
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Prescription meds- Age-first use
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Prescription med-Most recent use
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Prescription meds - How often
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Prescription meds - How admin
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Nicotine - Age at first use
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Nicotine - Most recent use
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Nicotine - How often
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Nicotine - How admin
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Other Abuse Comments
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Substance Abuse Treatment
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Substance Abuse Including
• • •
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Reactions to Treatment Received
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Experience with self-help groups
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Self-help groups - AA
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Self-help groups - NA
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Self-help groups - Al-non
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Affc'td by alcohol use- Fam Mem
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Affc'td by alcohol use-Other Mem
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Affected by drug use- Family mem
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Affected by drug use- Other Mem
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Fam mem alcohol use affc'td most
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Oth mem alcohol use affc'td most
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Fam mem drug use affected most
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Other mem drug use affceted most
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CLIENT’S MENTAL HEALTH STATUS
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Client Sleep
• • •
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Sleep
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Sleep - How many hours
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Sleep - # of wake up
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Hard to fall asleep
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Hard to get back to sleep
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Appetite/Dietary Habits
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Appetite/Dietary Habits
• • •
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Appetite/Dietary Habits Duration
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Appetite/Dietary
• • •
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Appetite/Dietary Comments
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Energy level
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Energy level - Usual
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Energy Level - Past 3 months
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Energy Level - Today
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Libido
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Sexually active
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Libido
• • •
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Practice Safe Sex
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Suicidal/homicidal
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Suicidal/homicidal
• • •
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Reliability
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Reliability-Clinician perception
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Appearance
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Client Appearance
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Client Appearance - Other
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Personal Hygiene
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Client Personal Hygiene
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Client personal hygiene other
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Behavior
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Client Behaviour
• • •
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Clothing
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Client Clothing
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Clothing (Describe if striking)
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Attitude
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Client Attitude
• • •
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Eye Contact
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Client - Eye Contact
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Change during interview (describ
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Speech
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Client Speech
• • •
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Psycho motor Activity
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Client - Psycho motor Activity
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Interaction during interview
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Client Interaction during interv
• • •
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Mood, Temperament & Emotional
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Emotional Range
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Client Emotional
• • •
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Client Mood
• • •
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Client Temperament
• • •
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Affect
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Client - Affect
• • •
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Perceptual disturbances
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Client - Perceptual disturbances
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Thought processes
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Client - Thought processes
• • •
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Content of thought
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Client Content of thought
• • •
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Information and intelligence
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Appropriate to age and education
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Orientation to
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Client Orientation to
• • •
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Able to concentrate
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Able to follow instructions
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Memory
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Client Memory
• • •
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Coordination
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Client Coordination
• • •
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Judgment & Insight
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Client Judgment & Insight
• • •
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Support Systems
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Support Systems - Family
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Support System Community
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Support Systems - Friends
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Community Professional Leaders
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Community Spiritual Leaders
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What brings you here today
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CRISIS & RISK ASSESSMENT
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Client Personal Hygiene Other
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Crisis Assessment 1 -10
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Risk Assessment 1 (low)-10 (High
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Risk to harm self
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Risk to harm to others
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Given Crisis Number
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Client Needs Crisis intervention
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Crisis plan necessary
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Client's Strengths
• • •
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Client's Challenges
• • •
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SUMMARY - Client issues
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SUMMARY - Any past services
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SUMMARY - Recommendations
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SUMMARY - Needs
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FIVE AXIS DIAGNOSIS
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Five axis diagnosis - #
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Five axis diagnosis - Descriptio
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Five axis diagnosis by history
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By History - By whom
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AXIS I
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AXIS II
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AXIS III
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AXIS IV
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AXIS V
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GAF(CURRENT)
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GAF (LAST YEAR)
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AC-OK Screening for Co-Occurring
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Adult: # of yes questions 1-7
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Adult: # of yes questions 8-13
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Adult: # of yes questions 14&15
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Adolescent (Ages 10-20)
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Adolescent - Questions 1-6
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Adolescent - Questions 7-12
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Adolescent - Questions 13-15
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Stages for Primary DX
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Client did not answer this time
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