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Assessment Date:
|
|
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Informant Name
|
Relationship
|
|
Informant Name
|
Relationship
|
|
Chief Complaint:
|
|
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Interval History
|
|
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Current Suicidal Ideation?
|
Intent? Plan?
|
|
Current Homicidal Ideation?
|
Intent? Plan?
|
|
Imminent Danger to Self?
|
Imminent Danger to Others?
|
|
Current Treatment?
|
|
|
Allergies
|
Medications
|
|
Risk/Safety Assessment:
|
|
|
Suicidal Ideation/Gestures
• • •
|
Describe
|
|
Homicidal Ideation/Gestures
• • •
|
Describe
|
|
Self-injurious Behaviors
• • •
|
Describe
|
|
Aggression (Identify Targets)
• • •
|
Describe
|
|
Sexualized Behavior
• • •
|
Describe
|
|
Access to Guns
• • •
|
Describe
|
|
Legal Issues
• • •
|
Describe
|
|
Other
• • •
|
Describe
|
|
Assessment:
|
|
|
Assessment
|
|
|
Mental Status Examination
|
|
|
Mental Status Exam
|
Appearance
|
|
Behavior
|
|
|
Motor
|
|
|
Speech
|
|
|
Mood
|
|
|
Affect
|
|
|
Thought Process
|
|
|
Thought Content
|
|
|
Impulse Control
|
|
|
Aims
|
|
|
Weight
|
|
|
Plan:
|
|
|
Plan:
|
|
|
DSM Diagnoses:
|
|
|
DSM Diagnoses:
|
|
