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