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Assessment Date:
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Informant Name
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Relationship
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Informant Name
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Relationship
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Chief Complaint:
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History of Present Illness:
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Current Suicidal Ideation?
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Intent? Plan?
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Current Homicidal Ideation?
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Intent? Plan?
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Imminent Danger to Self?
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Imminent Danger to Others?
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Developmental History:
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Past Medical/Surgical History:
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Review of Systems:
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Past Psychiatric History:
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Past Psychiatric Medications:
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Current Treatment?
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Allergies
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Medications
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Risk/Safety Assessment:
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Suicidal Ideation/Gestures
• • •
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Describe
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Homicidal Ideation/Gestures
• • •
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Describe
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Self-injurious Behaviors
• • •
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Describe
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Aggression (Identify Targets)
• • •
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Describe
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Sexualized Behavior
• • •
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Describe
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Access to Guns
• • •
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Describe
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Legal Issues
• • •
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Describe
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Other
• • •
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Describe
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Trauma/Abuse History:
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Sexual Abuse
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Describe
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Physical Abuse
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Describe
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Neglect
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Describe
|
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Other Trauma
|
Describe
|
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Trauma Associated Symptoms Present:
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Family History
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Family History of Suicide?
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Describe
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Family History of Substance Abuse?
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Describe
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Family History:
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Social History
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Social History Description:
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Vital Signs
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Assessment:
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Assessment
|
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DSM Diagnoses:
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DSM Diagnoses:
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Mental Status Exam
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Mental Status Exam
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Appearance
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Behavior
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Motor
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Speech
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Mood
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Affect
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Thought Process
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Thought Content
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Impulse Control
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Aims
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Weight
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Plan:
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Plan:
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