for phyllis only

Client Name:

Date of Birth:

Date of Assessment:

Presenting Situation (Use this section to describe the client’s presenting situation. Specifically address what the client is requesting in terms of assistance, services, and change objectives/goals. As much as possible, use the client’s own words in this section.):

Strengths and Resources: (This is a very important section. Help the client brainstorm personal strengths and resources in their environment that will help them make the changes they desire.

Potential Barriers: (This is another critical area to explore with the client. Help them think about barriers to achieving their change goals — barriers that already exist as well as barriers that may come up as they begin to work toward their goals. You do not have to solve them here; just identify them. Explain to the client that their case manager will come back to these barriers when they work with the client on developing their individualized service plan.)

Culture and Language Considerations: (Are there any particular culture or language issues or needs that the client wishes you to be aware of? These may not be apparent, so you need to ask in a supportive and welcoming way if there are special or unique things about them or their family that they want you to know. Also ask if they have any special learning issues or needs regarding written or verbal communications.)

Current Client Involvement with Other Agencies and Services:

Assessments of Client Domains: (Briefly describe the client’s status in each of the following domains. If they indicate none or choose not to answer a particular item, just note “client declines at this time.” This is a valid option for any of the questions and information requested in this assessment. Case managers should never force a client to respond to something that makes them uncomfortable.)

Family:

Social:

Spiritual:

Housing:

Education:

Employment:

Access to health and dental care:

Transportation:

Hobbies and recreation:

Other:

Current Medications:

Name/Dosage:

Side effects:

Medication allergies:

Prescribed by:

Safety and Trauma History:

Are you safe in your current living situation? (Yes/No) _______

Do you feel threatened in any way? (Yes/No) _____

If yes, please describe:

Are you now, or have you in the past, experienced trauma of any kind? (Yes/No) ____

If yes, indicate all that apply:

Emotional:

Sexual:

Physical:

Provide a brief description of this and your present status. Include a brief statement of any previous treatments or services you have received for this trauma(s) and whether or not you have any remaining symptoms or issues you would like help with.

If applicable, do you have a safety plan? (Yes/No)______

Do you need immediate help today to gain safety? (Yes/No)______

Client’s Legal History:

Suicide/Homicide Risk Evaluation: (For each of the following, use the scale: 1-None, 2 – Slight, 3 – Moderate, 4 - Extreme/Immediate)

Client’s self-rating of suicide risk: (Indicate 1, 2, 3, or 4)

Client’s self-rating of becoming violent: (Indicate 1, 2, 3, or 4)

Client’s self-rating of homicide risk: (Indicate 1, 2, 3, or 4)

Self-harm Risk Evaluation: (1-Never, 2 – Once, 3 – Occasionally, 4 - Frequently)

Have you ever cut yourself or purposely injured yourself in any way? (1-Never, 2 – Once, 3 – Occasionally, 4 - Frequently)

Safety Plan Based on Client Risk Self-Assessment: (You must complete this section if the client rates any of the previous areas as a 2, 3, or 4. Describe what the client reports and their assessment of their current level of risk or safety. If they have a safety plan briefly describe it here.)

Client Status (caseworker observation of client report)

Appearance:

Age appropriate (Yes/No)______

Well groomed (Yes/No)______

Disheveled/unkempt (Yes/No)______

Other – explain (Yes/No)______

Orientation (Is client aware of the following?):

Where they are (Yes/No)______

Why they are here (Yes/No)______

Day and time (Yes/No)______

Their situation (Yes/No)______

Current events (Yes/No)______

Behavior/Body Language:

Open (Yes/No)______

Good (Yes/No)______

Limited (Yes/No)______

Avoidant (Yes/No)______

None (Yes/No)______

Relaxed/calm (Yes/No)______

Restless (Yes/No)______

Rigid (Yes/No)______

Agitated (Yes/No)______

Slumped posture (Yes/No)______

Tense (Yes/No)______

Tics (Yes/No)______

Tremors (Yes/No)______

Other – explain

Motor Activity:

Full ability (Yes/No)______

Minor impairment (Yes/No)______

Serious impairment (Yes/No)______

Catatonic behavior other – explain

Manner:

Friendly (Yes/No)______

Trusting (Yes/No)______

Cooperative (Yes/No)______

Nervous (Yes/No)______

Withdrawn (Yes/No)______

Playful (Yes/No)______

Evasive (Yes/No)______

Guarded (Yes/No)______

Quiet (Yes/No)______

Passive (Yes/No)______

Defensive (Yes/No)______

Hostile (Yes/No)______

Agitated (Yes/No)______

Demanding (Yes/No)______

Speech:

Clear (Yes/No)______

Understandable (Yes/No)______

Incoherent (Yes/No)______

Rapid (Yes/No)______

Quiet (Yes/No)______

Loud (Yes/No)______

Slurred (Yes/No)______

Slow (Yes/No)______

Mood:

Appropriate (considering presenting situation) (Yes/No)______

Depressed (Yes/No)______

Irritable (Yes/No)______

Anxious (Yes/No)______

Euphoric (Yes/No)______

Fatigued (Yes/No)______

Angry (Yes/No)______

Expansive (Yes/No)______

Unable to evaluate – explain (Yes/No)______

Affect:

Appropriate (considering presenting situation) (Yes/No)______

Warm (Yes/No)______

Welcoming (Yes/No)______

Tearful (Yes/No)______

Blunted (Yes/No)______

Constricted (Yes/No)______

Flat (Yes/No)______

Labile (Yes/No)______

Excited (Yes/No)______

Anhedonic (Yes/No)______

Sleep:

Excellent (Yes/No)______

Good (Yes/No)______

Fair (Yes/No)______

Poor (Yes/No)______

Increased (Yes/No)______

Decreased (Yes/No)______

Initial insomnia (Yes/No)______

Middle insomnia (Yes/No)______

Terminal insomnia (Yes/No)______

Client reports concern about sleep pattern (Yes/No)______

Appetite:

Excellent (Yes/No)______

Good (Yes/No)______

Fair (Yes/No)______

Poor (Yes/No)______

Increased (Yes/No)______

Decreased (Yes/No)______

Weight gain (Yes/No)______

Weight loss (Yes/No)______

Client reports concern about appetite or weight (Yes/No)______

Thought Process:

Logical and well organized (Yes/No)______

Illogical (Yes/No)______

Flight of ideas (Yes/No)______

Circumstantial (Yes/No)______

Loose associations (Yes/No)______

Rambling (Yes/No)______

Obsessive (Yes/No)______

Blocking (Yes/No)______

Tangential (Yes/No)______

Spontaneous (Yes/No)______

Perseverative (Yes/No)______

Distractible (Yes/No)______

Thought Content:

Appropriate (considering presenting situation) (Yes/No)______

Delusions (Yes/No)______

Paranoid delusions (Yes/No)______

Distortions (Yes/No)______

Thought withdrawal (Yes/No)______

Thought insertion (Yes/No)______

Thought broadcast (Yes/No)______

Magical thinking (Yes/No)______

Somatic delusions (Yes/No)______

Ideas of reference (Yes/No)______

Delusional guilt (Yes/No)______

Grandiose delusions (Yes/No)______

Nihilistic delusions (Yes/No)______

Ideas of inference (Yes/No)______

Unable to evaluate – explain

Perceptions:

Appropriate (considering presenting situation) (Yes/No)______

Illusions (Yes/No)______

Hallucinations (Yes/No)______

Depersonalization (Yes/No)______

Derealization (Yes/No)______

Unable to evaluate – explain (Yes/No)______

Judgment:

Intact (Yes/No)______

Age appropriate (Yes/No)______

Impulsive (Yes/No)______

Immature (Yes/No)______

Impaired (Yes/No)______

Mild (Yes/No)______

Unable to evaluate – explain (Yes/No)______

Client reports (Yes/No)______

Insight:

Intact (Yes/No)______

Limited (Yes/No)______

Very limited (Yes/No)______

Fair (Yes/No)______

None (Yes/No)______

Aware of current situation (Yes/No)______

Understands internal and external factors involved in current situation (Yes/No)______

Unable to evaluate – explain (Yes/No)______

Client reports (Yes/No)______

Memory:

Intact (Yes/No)______

Impaired (Yes/No)______

Immediate recall (Yes/No)______

Remote (Yes/No)______

Unable to evaluate – explain (Yes/No)______

Amnesia (Yes/No)______ (type of amnesia) ___________

Cognitive functioning:

No issues noted (Yes/No)______

Issues noted – describe (Yes/No)______

Client reports (Yes/No)______

Substance Use/Abuse:

Experiencing:

Withdrawal (Yes/No)______

Blackouts (Yes/No)______

Hallucinations (Yes/No)______

Vomiting (Yes/No)______

Severe depression (Yes/No)______

DTs and shaking (Yes/No)______

Seizures (Yes/No)______

Other (Yes/No)______

If yes, describe:

Patterns of Use:

Do you use more under stress? (Yes/No)______

Do you continue to use when others have stopped? (Yes/No)______

Have you lied about consumption? (Yes/No)______

Have you tried to avoid others while using? (Yes/No)______

Have you been drunk/high for several days at a time? (Yes/No)______

Do you sometimes neglect obligations when using? (Yes/No)______

Do you sometimes use more than you intended? (Yes/No)______

Are you finding you need to increase use to get the effect you desire? (Yes/No)______

Have you tried to hide consumption? (Yes/No)______

Do you sometimes use before noon? (Yes/No)______

Do you find you cannot limit use once begun? (Yes/No)______

Have you failed to keep promises to reduce use? (Yes/No)______

Do you arrange your day around your substance use? (Yes/No)______

Have you attempted to reduce or stop before? (Yes/No)______

What happened?

Describe the circumstances that usually lead to a relapse for you:

Do you want to reduce or stop using the substances described above? (Yes/No)______

Do you have depression or other mental health issues that you believe affect your use of substances? (Yes/No)______

If yes, please describe:

Are you presently involved in AA/NA? (Yes/No)______

What are your goals for change in this area?

DSM 5 Diagnostic Impression (Diagnostic Impression means an interpretive statement based upon previous and current evaluative data. A diagnostic impression may or may not make reference to DSM criteria):

Clinical Summary: (Using the information you have gathered at this point, provide a brief summary of the presenting issues, client strengths and needs, any immediate risks, and the client’s goals for change. You will be reviewing this assessment and your summary and recommendations with the client and with your clinical supervisor so be sure to write in terms the client can understand and relate to (avoid technical jargon) and maintain a strengths-based and empowerment perspective.)

Recommendations: (including specific service recommendations)

Disposition: (clearly describe the next steps and what this client can expect next from your agency. If you have already arranged an intake with a case manager or a counselor, include the name of the worker, their credentials, and the date and time of the next appointment.)

Client Signature:

Date:

Legal Guardian’s Signature (if one is assigned or if client is under 18):

Date:

Case Manager Signature:

Date:

________________________________________