Please complete the form below
    7. Contact Address
      10. MENTAL STATUS EXAM: APPEARANCE
    10. Well GroomedNeat / CleanDishevelledPoor HygieneOther
      11. MENTAL STATUS EXAM: ORIENTATION
    11. PersonPlaceTime
      12. MENTAL STATUS EXAM: SPEECH
    12. Normal (Rate, Tone & Volume)DisorganizedPressuredSlurred
      13. MENTAL STATUS EXAM: BEHAVIOR
    13. CooperativeUncooperativeGuardedFriendlyThreateningAngry
      14. MENTAL STATUS EXAM: PSYCHOMOTOR ACTIVITY
    14. HyperactivityExcessive FidgetingAgitationNormal
      15. MENTAL STATUS EXAM: MOOD
    15. EuthymicEuphoricDysphoricAnxiousAngryIrritable
      16. MENTAL STATUS EXAM: AFFECT
    16. FullConstrictedLabileBluntedFlat
      17. MENTAL STATUS EXAM: THOUGHT PROCESS
    17. Goal-Directed and Logical AppropriateTangentialFlight of Ideas Circumstantial DisorganizedBlockingLoose Associations PerseverationIdeas of ReferencePoverty of Thought
      18. MENTAL STATUS EXAM: THOUGHT OF CONTENT
    18. AppropriateHomicidal IdeationSuicidal IdeationPersecutory Delusions
      19. MENTAL STATUS EXAM: HALLUCINATIONS
    19. AuditoryVisualOlfactoryCommandTactile
      20. MENTAL STATUS EXAM: SHORT TERM MEMORY
    20. IntactFairImpaired
      21. MENTAL STATUS EXAM: INSIGHT
    21. IntactFairImpaired
      22. MENTAL STATUS EXAM: JUDGMENT
    22. IntactFairImpaired
      24. PAST PSYCHIATRIC HISTORY: Prior Psychiatric Admissions
      25. PAST PSYCHIATRIC HISTORY: Sexual Abuse
      26. PAST PSYCHIATRIC HISTORY: Physical Abuse
      27. PAST PSYCHIATRIC HISTORY: Suicide Attempts
      28. ALCOHOL & DRUG USE HISTORY: Status
    28. UnknownNo current substance abuse No past substance abuseCurrently clean and sober
      29. ALCOHOL & DRUG USE HISTORY: Alcohol
    29. PastPresent
      30. ALCOHOL & DRUG USE HISTORY: Cocaine
    30. PastPresent
      31. ALCOHOL & DRUG USE HISTORY: Opiates
    31. PastPresent
      32. ALCOHOL & DRUG USE HISTORY: Sedatives PastPresent
    32. PastPresent
      33. ALCOHOL & DRUG USE HISTORY: Nicotine
    33. PastPresent
      34. ALCOHOL & DRUG USE HISTORY: Marijuana
    34. PastPresent
      35. ALCOHOL & DRUG USE HISTORY: Ecstasy
    35. PastPresent
      36. ALCOHOL & DRUG USE HISTORY: Inhalants
    36. PastPresent
      37. ALCOHOL & DRUG USE HISTORY: Caffeine
    37. PastPresent
      38. ALCOHOL & DRUG USE HISTORY: Amphetamines
    38. PastPresent
      39. ALCOHOL & DRUG USE HISTORY: Hallucinogens
    39. PastPresent
      40. MEDICATIONS
      41. SUBSTANCE ABUSE HISTORY
      43. FAMILY PSYCHIATRIC HISTORY
      44. SOCIAL HISTORY: EDUCATION
      45. SOCIAL HISTORY: LIVING SITUATION
      46. SOCIAL HISTORY: EMPLOYMENT
      47. MILITARY HISTORY (*If any)
      49. LEGAL HISTORY (*if applicable)
    50. Victim of Physical Abuse Victim of Sexual Abuse Trauma or Loss in the FamilyDomestic Violence: Victim" Domestic Violence: PerpetratorHistory of Substance AbuseHistory of Assaultive BehaviorHistory of Threatening BehaviorHistory of Inappropriate Sexual BehaviorBehavior Influenced by Delusions or HallucinationsHistory of Self-injurious BehaviorHistory of Suicidal BehaviorFamily History of SuicideAccess to Firearms (family, friends, selfAccess to Other Means of SuicideLack of Social SupportHistory of Foster CareHomelessness
      51. CURRENT RISK ASSESSMENT
      54. Clinical Summary (Optional) Medication benefits and potential side effects have been explained to the patient.
    54. YesNoNot Applicable
      55. DIAGNOSTIC IMPRESSION: DSM Code and Narrative – Designate diagnosis which is the primary & secondary focus of treatment. Primary
      57. Secondary
      59. ICD-10 DIAGNOSIS: Problem List Diagnosis #1
      60. ICD-10 DIAGNOSIS: Problem List Diagnosis #2
      61. ICD-10 DIAGNOSIS: Problem List Diagnosis #3
      62. ICD-10 DIAGNOSIS: Problem List Diagnosis #4
      63. ICD-10 DIAGNOSIS: Problem List Diagnosis #5
      64. INITIAL TREATMENT PLAN / TARGETED CASE MANAGEMENT Does the client meet the criteria for TCM? (May include moderate or above Functional Impairment and/or risk of losing placement/housing, need for financial support, social support, prevocational/employment assistance, rehabilitation,or other programs or services considered necessary.)
    64. YesNo
      65. Explain Referral to Coordination of Care with:
    65. Case Management Psychotherapist Community Support WorkerSocial WorkerVocational TherapistFamily SupportSubstance Abuse Agency
      66. Details: Medications prescribed / Dosage / Frequency & other details EVALUATION CONTROL Medication Information Sheet for each medication was given to the client and family.Benefits/Risks/Possible adverse effects of medication and alternatives to medication have been discussed.Opportunity was given to ask questions.The client and/or family appear to understand the information on the form.If appropriate, discuss the interaction of psychiatric medication with the following: Pregnancy, Lactation, Alcohol, Nutrition, and Non-Psychiatric Medications. Client (Family) is able to manage own medication
    66. YesNo
      67. If not, explain 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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