Please complete the form below
    3. Black / AfricanAfrican-AmericanHispanic / LatinoWhiteMultiracial
      10. CHECK AND COMPLETE ALL THAT APPLY
    10. The client has undergone two or more episodes of inpatient care for a mental illness within the preceding twenty-four months.This person has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months duration within the preceding twelve months.
    12. This person has been treated by a crisis response team tow or more times within the preceding 24 months.This person has a diagnosis of schozophrenia, schizoaffective disorder, major depressive disorder,bipolar and/or borderline personality disorder and is reasonably likely to have future episodes requiring inpatient or residential treatment of a frequency described above unless case mangement services are provided.In the past three years, the client has been committed by a court as a mentally ill person under the statutes of the state of this person's commitment has been stayed or continued for reasons related to this person's mental illness. This person has been eligible for case management services under one of the above items or was eligible as a child for such services and is reasonably likely to have future episodes requiring inpatient or residential treatment of a frequency described above without case management services.This person is seriously mentally ill, has three or more functional impairments, and medically necessary to maintain stability or improve functioning in the community through skill development in the area of basic living.
      13. SYMPTOMS AND BEHAVIORS THAT IMPACT A CLIENT'S FUNCTIONING Multiple choices is possible Depressed MoodDecreased EnergySocial WithdrawalSleep Disturbances Hopelessness HelplessnessGriefGuiltIrritabilityElevated MoodImpulsivityDistractibilityHyperactivityObsessionsCompulsionsSomatic Complaints Disruption of Thought ProcessDelusionsAuditory hallucinations Visual hallucinations Tactile hallucinations Dissociative StatesAnxietyPanic Attacks AgoraphobiaEmotional / Physical / Sexual Trauma (Victim) Emotional / Physical / Sexual Trauma (Perpetrator) Suicidal IdeationHomicidal IdeationSelf-injurious Behavior Property DestructionFire SettingCruelty to AnimalsStealingLying / Manipulation Sexual Acting OutSexual PromiscuityActive Substance AbuseEarly Full Substance Abuse RemissionSustained Full Substance Abuse RemissionSustained Partial Substance Abuse Remission Concomitant Medical Condition Please elaborate below on most significant symptoms identified above and how they interfere with client functioning: What is the current mental status of the client? Please provide a history of the client's mental illness. Please describe the client's medical history and any current medical problems (include current medications): Please provide a family history of medical issues: Please provide a history of developmental issues: CLIENT STRENGTHS, FUNCTIONAL IMPAIRMENTS / VULNERABILITIES: Mention identified strength, functional impairments/vulnerabilities due to mental health symptoms & describe the impairments/vulnerabilities due to mental health symptoms. Mental Health Symptom Management: Mental Health Service Needs Use of Drugs or Alcohol (include current, history & family history Vocational Functioning (employment status) Educational Functioning (educational level) Social Functioning (indicators on leisure time, communication skills, support network, cultural influences & impact, community resources utilization & integration and belief system) Interpersonal Functioning (indicators on relationship with family, judgment and intellect (problem-solving, coping skills) Self-Care and Independent Living Capacity (indicators on healthy lifestyle skills, household management skills, budgeting skills, shopping skills). Medical / Dental Health Care Practices (indicators on medical care coverage, mental health care directives, dental care and family medical history) Obtaining and Maintaining Financial Assistance Obtaining and Maintaining Housing Using Transportation Sexuality Safety and Prevention Vulnerabilities (indicators of financial exploitation, physical abuse, sexual abuse, passivity, presence of suicidal or self-injurious behaviors, demonstrated violence towards others, negative social behaviors). CAGE (CHEMICAL DEPENDENCY QUESTIONS Have you ever felt you ought to cut down on your drinking or drug use? YesNo Have people annoyed you by criticizing your drinking or drug use? YesNo Have you ever felt bad or guilty about your drinking or drug use? YesNo Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? YesNo OTHER NEEDED ASSESSMENTS Psychological Testing NeededNot Needed Neurological Examination NeededNot Needed Physical Examination NeededNot Needed Chemical Dependency Assessment NeededNot Needed What are the client's service needs and what are your recommendations? NeededNot Needed COMPLETED BY: Name of Mental Health Professional DATA ENTRY DATE By submitting this form, the provider acknowledges all information provided was at the consent of the client (family) and caregiver & intended solely for treatment purposes.

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