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Name: ________________________________________________________________ Gender: __________________ Date of Birth: _____/______/_______ Marital Status ______________ Race/Ethnicity: ___________________________ Languages Spoken: _____________________________________________________

Chief Complaint: _____________________________________________________________________

History of Present Illness: __________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Psychiatric/Psychological History:

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Past Medical History: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Surgical History: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies: _____________________________________________________________

Current Medication List

Past Medication List

Comments:

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Drug/Alcohol Assessment

Suicidal/Homicidal Ideation

Is there a suicide risk? ___ No ___ Yes ___ Previous attempt (When: _____________________________________________) ___ Current plan ___ Means to carry out plan ___ Intent ___ Lethality of plan Is the patient dangerous to others? ___ Yes ____ No Does the patient have thoughts of harming others? ___ Yes ___ No If yes: Target: __________________________________________________________ Can the thoughts of harm be managed? ___ Yes ___ No ___ Current plan ___Means to carry out plan ___ Intent ___ Lethality of plan High risk behaviors ___ None ___ Cutting ___ Anorexia/Bulimia ___ Head Banging ___ Self injurious behaviors ___ Other: _____________________________________________________________

Abuse Assessment

In the past year has the patient been hit, kicked, or physically hurt by another person? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the patient in a relationship with someone who threatens or physically harms them? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the patient been forced to have sexual contact that they were not comfortable with? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the patient ever been abused? ___ Yes ___ No. If yes, describe by whom, when and how. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family/Social History

Born/raised ________________________________________ Siblings ___ # of brothers ___ # of sisters What was the birth order? ____of ____ children Who primarily raised the patient? ___________________________________________ Describe marriages or significant relationships: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number of children: _____________________________________________________ Current living situation: __________________________________________________ Military history/type of discharge: __________________________________________ Support/social network: __________________________________________________ Significant life events: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family History of Mental Illness (which relative and which mental illness): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Employment

What is the current employment status? ___________________________________ Does the patient like their job? _____________________________________________ Will this job likely be done on a long-term basis? _______________________________ Does the patient get along with co-workers? __________________________________ Does the patient perform well at their job? ____________________________________ Has the patient ever been fired? Yes No If yes, explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How many jobs has the patient had in the last five years? ________________________

Education

Highest grade completed: ________________________________________________ Schools attended: _______________________________________________________ Discipline problems: _____________________________________________________

Current Legal Status

_____ No legal problems _____ Probation _____ Previous jail

Developmental History

_____ Parole _____ Charges pending _____ Has a guardian

Describe the childhood: Describe the childhood in relation to personality, school, friends, and hobbies): _____ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Describe any traumatic experiences in the childhood: (List the age when they occurred) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ What is the patient’s sexual orientation? ___ Heterosexual ___ Homosexual ___ Bisexual

Spiritual Assessment

Religious background: ___________________________________________________ Does the patient currently attend any religious services? Yes No If yes, where. ______________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cultural Assessment

List any important issues that have affected the ethnic/cultural background.

Financial Assessment

Describe the financial situation. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___ Traumatic ___ Painful ___ Uneventful

Coping Skills

Describe how the patient copes with stressful situations. ______________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the patient’s coping methods: ___ adaptive ___ maladaptive

Interests and Abilities

What hobbies does the patient have? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What is the patient good at? ______________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What gives the patient pleasure? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MENTAL STATUS ASSESSMENT

(Describe any deviation from normal under each category.)

Arousal/Orientation

___ Alert ___ Sleepy ___ Attentive ___ Unresponsive ___ Oriented to person ___ Oriented to place ___ Oriented to time ___ Confused ___ Other: _____________________________________________________________

Appearance

___ Well groomed ___ Good eye contact ___ Poor eye contact ___ Disheveled ___ Bizarre ___ Poor hygiene ___ Inappropriate dress ___ Other:____________________________________________________________

Behavior/Motor Activity

___ Normal ____ Restless ____ Agitated ___ Lethargic ___ Abnormal facial expressions ___Tremors ___ Tics ___ Other:____________________________________________________________

Mood/Affect

___ Normal ____ Depressed ___ Flat ____ Euphoric ___ Anxious ___ Irritable ___ Liable ___ Indifferent ___ Careless ___ Inability to sense emotions ___ Lack of sympathy ___ Other:_____________________________________________________________

Speech

___ Normal ___ Nonverbal ___Slurred ___ Soft ___ Loud ___ Pressured ___ Limited ___ Incoherent ___ Halting ___ Rapid

___ Other: ____________________________________________________________

Attitude

___ Cooperative ___ Uncooperative ___Guarded ___ Suspicious ___ Hostile ___ Other: _____________________________________________________________

Thought Process

___ Intact ___ Flight of ideas ___ Tangential ___ Concrete thinking ___ Loose associations ___ Unable to think abstractly ___ Circumstantial

___ Neologisms ___ Racing ___ Word Salad ___ Other: _____________________________________________________________

Thought Content

___ Normal ___ Phobia ___ Hypochondriasis ___ Delusions ___ Obsessive ___ Preoccupations ___ Other: _____________________________________________________________

Delusions

___ None ___ Religious ___ Persecutory ___ Grandiose ___ Somatic ___ Ideas of reference ___Thought broadcasting ___Thought insertion ___ Other: ____________________________________________________________

Hallucinations

___ None ___ Auditory hallucinations ___ Visual hallucinations ___ Command hallucinations ___ Other: _____________________________________________________________ Describe: ______________________________________________________________ ______________________________________________________________________

Impulse Control

___ Normal ___ Partial ___ Limited ___ Poor ___ None ___ Frequently participates in activities without planning or thinking about them

Judgment

(What would you do if there was a fire in a crowded movie theater?) ___ Normal ____ Poor

Cognition/Knowledge

Orientation

___ Person ___ Place ___ Time

Attention

Can the patient spell W-O-R-L-D backwards? ___ Yes ___ No

Memory

Immediate recall of 3 objects ___/3 Recall after 5 minutes ___/3

Naming

Point out three objects. How many can the patient name? ___/3

Visual-spatial

Can the patient copy intersecting pentagons? ___ Yes ___ No

Praxis

Can the patient follow a three step command? ___ Yes ___ No

Calculations

Serial 7’s (how many times can the patient correctly subtract 7 from 100): __________

Abstractions

___ Comprehends ___ Does not comprehend

Insight

___ Normal ___ Poor Is the patient able to meet their basic needs (e. g., food, shelter, medical):

___ Yes ___ No If no, Describe: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Functional Ability

Check the area of concern ___ None ___ Activities of daily living ___Work ___ Family relationships___ Social relationships ___ Cognitive functioning ___ Physical health ___ Housing ___ Impulse control ___ Social skills

___ Finances ___ School ___ Safety ___ Legal

IMMEDIATE TREATMENT PLAN:

DX to RO (Rule Out):

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Immediate Treatment Goals & Objectives:

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Signature: _______________________________ Date: _______________________