Clinical Diagnostic Assessment[1]

Consumer Name:

CID#

CLINICAL DIAGNOSTIC ASSESSMENT

Date of Assessment: What are the presenting problems? Severity, Frequency, and Duration of chief complaint? Discuss recurring symptoms/behaviors, functional risks? Onset of problems? (Include relevant psychological and social conditions affecting psychiatric status)

Why seeking treatment now (any early indications or significant behaviors that could be disruptive/risk to community/family/school, significant)?

Symptoms currently experiencing: Sleep Disturbance Appetite Disturbance Episodic crying Low Energy Depressed Mood Inattentive/Not focusing Feelings of worthlessness Runaway behavior

Truancy Lying/ Manipulative Self-injurious Behavior Obsessions/Compulsions Poor Concentration Mood Liability Irritability Anxiety/Panic Attacks Panic Attacks Stealing

Impulsivity Hyperactivity Sexual Acting Out Delusions Paranoid Ideations Loose Associations Hallucinations Suicidal or Homicidal thoughts/behaviors Oppositional/Defiant

Aggressive Behavior Binging/Purging Anorexia Alcohol Use or Abuse Drug Use or Abuse Bed Wetting Social Withdrawal RX Meds Isolating from others

Explain details of each above and I/D other symptoms/behaviors not listed (i.e. severity, frequency, duration):

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc.

REVJUL 2008 1

Consumer Name:

Psychosocial Stressors/Events: Recent Death Physical Abuse Sexual Abuse Emotional Abuse Recent Hospitalization Legal Issues

CID# Relapse School Problems Custody Issues Placement Issues

Mental Health Treatment History □Prior or Current Psychotherapy or Psychiatric Treatment? (Include when, why, with whom, length and type of treatment, was treatment considered successful, and why was it discontinued)?

□Current or history of psychotropic medication? (Include dosages, frequency, etc.). □Family History of Mental Health Treatment/Diagnosis?

□Ever hospitalized in an in-patient facility? State when and where. □History of Suicide Attempts? □History of self-injury/self-mutilation??

Medical History

□Name of Current Physician/ or Practice Name: □Date of last physical? □Are immunizations up to date? Yes No □Passed Vision Screen? Yes No □Passed Hearing Screen? Yes No □Results of last dental exam? □Any Medical Condition (s)? Yes No If yes, what effect medical condition has on consumer’s level of physical functioning and mental health?

□Allergies: □Current medication(s)? □Any significant Family Medical History?

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc.

REVJUL 2008 2

Family History Current Relationship: (children & adolescents inquire about their parents, if applicable) Married Domestic Partner Separated Single None Discuss length, history, status of relationship, supportive, problems:

List Names of other children in the family and their ages: 1) Age: 5) 2) Age: 6) 3) Age: 7) 4) Age: 8) Consumers Birth Order:

of of

children born to natural parents adopted by parents

Siblings (natural and blended family structures): Name/Gender Name/Gender Name/Gender Name/Gender

Age: Age: Age: Age:

Number of family members who currently live in the household: (List names if they are not listed above) 1) 2) 3) 4) Consumer was born and raised where, what hospital, by whom:

Age: Age: Age: Age:

Skill/Ability Assessment Personal Hygiene Household Tasks Cooking/Nutrition Personal Safety Leisure/Recreational Social/Family Relations

Coping Skills/ Emotional Mgmt Childcare/Parenting Financial Management Medical/Medication Mgmt Mobility Within Community Specify Other

Needs/ Resource Assessment Housing Family/Social Support Community Involvement/Support Financial Healthcare

Transportation Education Vocational Specify Other Specify Other

Abilities, Willingness to participate & Responsibility Consumer Overall Attitude Towards Treatment

Preferences/Hopes for Recovery (in consumer’s own words)

Educational History 1. Last grade level completed: 2. School setting? Type of Classroom Placement: 3. Number and grade levels of retentions: 4. Is the student support team (SST) currently serving the child? Yes No 5. Does the child have an IEP? Yes No 6. Rate the child’s attendance in school and also give the number of days absent in the last 30 days (request and review the school records if needed).

Mental Status Exam (check all that apply) Attention

Good

Fair ( task 78%)

Easily Distracted

Highly Distractible

Affect

Appropriate

Labile

Expansive

Constricted

Mood

Normal

Appearance

Well-groomed

Disheveled

Bizarre

Motor Activity

Calm

Hyperactive

Agitated

Tremors

Tics

Thought Process

Intact

Circumstantial

Tangential

Flight of Ideas

Loose Associations

Hallucination

None

Auditory

Visual

Olfactory

Command

Delusions

None

Persecutory

Grandiose

Religious

Memory

Intact

Impaired

Immediate

Recent

Judgment/Insight

Intact

Impaired:

Mild

Moderate

Orientation

All Spheres

Impaired:

Person

Suicidal

None

Ideation

Plan

Intent

Means

Homicidal

None

Plan

Intent

Means

Speech

Normal

Pressured

Rapid

Depressed

Anxious

Ideation Slow

Slurred

Blunted

Euphoric Inappropriate

Place

Muscle Spasms

Other _________________ Remote Severe Time

Purpose

Other Comments:

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc.

RevAUG 2008 4

Functional Impairments (Estimate the effect behavioral problems or emotional distress has on the following): Family Relationship with S/O & other Primary R/T Physical Health Work School Spiritual/Sense of Meaning Social/Activity Level

None None None None None None None

Mild Mild Mild Mild Mild Mild Mild

Moderate Moderate Moderate Moderate Moderate Moderate Moderate

Severe Severe Severe Severe Severe Severe Severe

Addiction/Chemical Use & Dependency Assessment (Include tobacco, alcohol, RX, abuse, over the counter and illicit drugs and relevant caffeine) Name of Drug

Frequency

Currently

By hx

Currently

By hx

Currently

By hx

Currently

By hx

Amount

Age & Years Started Use/Abuse

□ Which is primary drug of choice, secondary, and third (if applicable)?

□ Last Use? (What drug did you experience recently, how long ago, how much)

□ Have received prior treatment for this issue (who, when, where, outcome):

□ Family History of Addiction/Chemical Abuse Treatment?

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc.

RevAUG 2008 5

Criminal/Legal History □

Discuss all past or recent criminal/illegal acts, charges, arrests, etc.?

□ On Parole? If yes, give details: □ On Probation? If yes, give details and obtain name of PO and a contact number: □

Court mandated (Criminal, Family Court, or Juvenile Court)

□

Other Status

DSM IV MULTI-AXIAL DIAGNOSIS AXIS I: (Primary)

AXIS I: (Secondary) AXIS II: AXIS III: AXIS IV:

AXIS V: Current GAF

_______

Highest GAF in the Past Year ______

I/D PROBLEMS TO BE CARRIED OVER FOR TREATMENT PLANNING: 1.

3.

2.

4.

INTERGRATIVE SUMMARY

Signature and Credentials

Print Name and Credentials

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc.

Date RevAUG 2008 7