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Initial Eval Header Affiliate Na
Service Type Comprehensive Asses
Reason seeking service (full sen
Client perception of needs inclu
Family’s perception of client’s
Environment barriers to services
• • •
...
The patient resides...City
Comments
Education: The client...
• • •
Comments
Employment:
• • •
Comments
Social - Pt. relies on...
• • •
Social spirit belief,attitude,pr
Social - leisure,rec.,hob inc:
...
Legal
• • •
...
Trauma history Ace Score
ACE Record Sheet
Other pertinent family&social
Gest, birth, delivery
• • •
Developmental
• • •
Developmental
Risk of Harm
Suicide Attempt History ?
How long ago?
Homicidal Attempt History ?
How long ago ?
Mental Health Treatment History
Inpatient Facility / Date
Outpatient Facility/ Date
Medical Issues
Current Medications
PCP
Date of last Physical Exam
Provisional Diagnosis / Rationale
Mental Status Exam (MSE)
General Observations
Appearance
• • •
Build
• • •
Demeanor
• • •
Eye Contact
• • •
Activity
• • •
Speech
• • •
Comments
Delusional
• • •
Other
• • •
Self-Abuse
• • •
Comments
Aggressive
• • •
Comments
Perception
Hallucinations
• • •
Comments
Thought Process
Process
• • •
Commenst
Mood
Mood Characteristics
• • •
Comments
Affects
Affect Characteristics
• • •
Comments
Behavior
Behavior Characteristics
• • •
Comments
Cognition
Insight/ Judgement
Characteristics
• • •
Impairment of :
• • •
Intelligence Estimate
• • •
Substance use/abuse Y/N
Reliabiltiy.
SUD History ?
Drug(s) of choice ?
Frequency of Use ?
SUD Treatment History/ Date
Tobacco
• • •
Tobacco
/
Cannabis
• • •
Age began / last used
/
Age began / last use
/
Age began / Age last used:
/
Alcohol
• • •
Age began / Age last used:
/
Cocaine
• • •
Age began / Age last used
/
Sedative Hypnotics
• • •
Age began / Age last used
/
Hallucinogens
• • •
Results
Opiates
• • •
Other
History of opiate treatment
• • •
Type and Results
Consequences of SUD
• • •
New Field
SUD treatment?
Detox
Family substance use and abuse
Amount used/ Last Use
ASAM level of care
Comments
Elaborative of Positive Mental Status Findings:
Additional Comments
Assessment Completed By:
Signature/ Date :
Supervisor Signature
Signature/ Date:

RBH Initial Assessment (SW) Medical Form

Psychologist

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Published: Sept. 14, 2020, 2:47 p.m.
Doctor: Dr. History Physical
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