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Assessment Type:
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Identifying Information
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Patients Living Arrangements:
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Primary Language Spoken in Household:
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Sexual Orientation(s)
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Marital Status
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Personal Spiritual/Cultural Belief System
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Religious/Spiritual Concerns Comment(s):
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Barriers to Treatment
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Barriers Comments
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Does the patient have children?
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Do children live with the patient?
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Medical History
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PCP
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Specialists
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Patient Current Medications
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Medical/Physical Problems
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Patient Psychiatric History
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Psychiatric History Includes
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Type of Hospitalization:
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Patient Hospitalized
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Patient Hospitalized When and Where
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DX and Medications Prescribed:
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Compliance with prescribed medication:
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Family History
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Paternal Family substance/alcohol abuse
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Maternal Family substance/alcohol abuse
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Paternal Family Mem History of suicide
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Maternal Family Mem History of suicide
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Paternal Family history of Mental Illness
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Maternal Family history of Mental Illness
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CLIENT'S DEVELOPMENTAL HISTORY
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Place of Birth
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Where was patient raised:
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Patient Raised By:
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Birth
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Development:
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Patient Relationship with Birth Mother:
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Patient Relationship with Birth Father:
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Patient # of Siblings(Name(s)/Ages:
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Patient Natural Support System Includes:
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EDUCATIONAL HISTORY
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Highest Level of Education Completed:
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Is patient diagnosed with intellectual disability?
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Learning Disabilities Comments
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Is patient currently enrolled in school?
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Patient Literacy Level
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MILITARY SERVICE
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Military Service
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Military Service Active Duty
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Military Service Branch
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Military - Date of Discharge
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Military - Type of Discharge
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VOCATIONAL HISTORY
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Employment Status
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History of Involuntary Termination:
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LEGAL HISTORY (Explain if Necess
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History of Legal Charges:
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Currently on Probation/Parole?
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Current Legal Problems
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Describe - Current Legal Charges:
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Is patient treatment court ordered?
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TRAUMA & ABUSE HISTORY
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Type of Abuse/Trauma Experienced by patient:
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Is patient perpetrator of abuse?
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Summary of Abuse
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SUBSTANCE USE HISTORY
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Do you drink caffeine beverages
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Caffeine Amount Daily
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Age drug use began
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Types of drug/s used:
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Nicotine
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Nicotine - Age at first use
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Nicotine - Most recent use
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Nicotine - How often and what amount
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Alcohol
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Alcohol - Age at first use
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Alcohol - Most recent use
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Alcohol - How often and what amount
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Alcohol - How Admin
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Marijuana
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Marijuana - Age at first use
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Marijuana - Most recent use
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Marijuana - How often and what amount
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Marijuana - How admin
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Cocaine
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Cocaine- Age at first use
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Cocaine- Most recent use
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Cocaine- How often and what amount
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Cocaine- How admin
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Hallucinogen
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Hallucinogen - Age at first use
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Hallucinogen - Most recent use
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Hallucinogen - How often and what amount
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Hallucinogen - How admin
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Heroin
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Heroin - Age at first use
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Heroin - Most recent use
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Heroin - How often and what amount
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Heroin - How admin
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Opioids
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Opioids - Age at first use
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Opioids - Most recent use
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Opioids - How often and what amount
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Opioids - How admin
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Meth
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Meth - Age at first use
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Meth - Most recent use
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Meth - How often and what amount
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Meth - How admin
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Amphetamines
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Amphetamines - Age at first use
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Amphetamines - Most recent use
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Amphetamines How often and what amount
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Amphetamines - How admin
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Benzo
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Benzos - Age at first use
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Benzos - Most recent use
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Benzos-How often and what amount
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Benzos - How administered
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Inhalants
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Inhalants - Age at first use
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Inhalants - Most recent use
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Inhalants-How often and what amount
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Inhalants - How administered
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MDMA
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MDMA - Age at first use
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MDMA - Most recent use
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MDMA-How often and what amount
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MDMA - How administered
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Other Abuse Comments
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DSM-Criterion
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DSM Criterion Met within 12 month period:
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Severity of Substance Disorder:
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CLIENT'S TREATMENT HISTORY
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Treatment for Addiction
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Types of treatment
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Reactions to Treatment Received
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PATIENT MENTAL HEALTH STATUS
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Client Orientation to
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Client - Affect
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Client - Thought processes
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Client Content of thought
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Client Memory
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Client Judgment & Insight
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Client - Perceptual disturbances
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Client Mood
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Able to concentrate
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Client Attitude
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Client - Psycho motor Activity
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Client Speech
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Client Appearance
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Client Hygiene
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Reliability-Clinician perception
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Suicidal/homicidal
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CRISIS & RISK ASSESSMENT
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Are your basic needs met?
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Are you at risk for HIV?
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Are you at risk for an STD or Hepatitis?
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Are you at risk for homelessness?
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Crisis Assessment
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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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Risk to harm self
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Risk to harm to others
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Risk Assessment 1 (low)-10 (High
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Crisis & Risk Comments
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Patient Strengths
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Patient's Challenges
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SUMMARY - Needs
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Referrals:
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SUMMARY AND RECOMMENDATIONS
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DSM-V Diagnosis:
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Assessment Completed by:
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Date Completed:
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