1915 C Assessment Form PDF Details

The 1915(c) Assessment form is a comprehensive document used primarily within the realm of behavioral health to gather extensive information pertinent to the evaluation and future care planning for individuals, particularly children and youth. This form encapsulates a wide array of data beginning with general demographic details and extending into more sensitive areas such as behavioral health history, substance use history, physical health conditions, medications, allergies, and even the individual's educational, familial, and social background. The form meticulously covers previous psychiatric treatments or hospitalizations, providing a deep dive into the mental health status through assessments of mood, thought processes, and risk assessment for self-harm or harm to others. Additionally, it touches upon the living situation and the legal status of the individual, aiming to capture a full picture that can guide appropriate care and interventions. Its sections on cultural and language preferences, alongside principal diagnoses and a summary with recommended treatments or linkages needed, underscore a personalized approach to mental health care. By focusing on such detailed facets of an individual's life and health, the 1915(c) Independent Behavioral Health Assessment form stands as a critical tool in developing tailored treatment plans aimed at addressing the complex, nuanced needs of those seeking behavioral health services.

QuestionAnswer
Form Name1915 C Assessment Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names1915 c assessment form, 1915 i independent behavioral health assessment, independent behavioral health assessment, behavioral health assessment 1915 c

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1915(C) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT

DEMOGRAPHIC INFORMATION

Child/Youth Name: (first, middle, last)

 

 

Assessment Date:

 

 

 

 

 

 

Age:

DOB:

Ethnicity:

Gender:

Gender Expression:

SSN:

 

 

 

 

 

 

Parent/Primary Caretaker Name: (first, middle, last)

Legal Guardian Name: (first, middle, last)

 

Is this person, the legal guardian?

 

□ Yes □ No (if not, enter information below)

Title/Department:

 

Phone Number:

 

 

 

BEHAVIORAL HEALTH HISTORY

I.CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health –in client/members’/caretaker’s own words/quoted.)

II. PRESENTING PROBLEM/RELEVANT HISTORY (Including client/member/caretaker/guardian reason for seeking services, precipitating factors, symptoms, behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and expectations.)

CURRENT BEHAVIORAL HEALTH PROVIDER NAME:

PHONE NUMBER:

 

 

III.PAST PSYCHIATRIC/PLACEMENT HISTORY (First onset of illness, past diagnostic and treatment history, medications, hospitalizations):

Prior Outpatient Mental Health Treatment: □ No; □ Yes;

Psychiatric Hospitalizations: □ No; □ Yes;

Detail:

Detail:

 

 

Prior Residential/Out of Home Placement: □ No; □ Yes;

 

Detail:

 

 

 

Additional History/Comments:

 

IV. SUBSTANCE USE HISTORY (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.)

Check any/all that apply in past 12 months:

□ Alcohol Use; □ Illegal Drug Use; □ Injected Drug Use ; □ Tobacco Product Use; □ Prescription Drug Misuse; □ Non-Prescription Drug (OTC) Misuse

□Alcohol and/or Drug Overdose; □ Alcohol and/or Drug Withdrawal; □ Problems caused by gambling; □ Trouble stopping any substance

□Other/Describe:

Substance Use Treatment History:

□ None; □ Outpatient;

□ Intensive Outpatient; □ Residential/Inpatient; □ Detox;

□ Other/Describe:

 

 

Hx of Drugs Used/Describe

 

 

 

 

 

 

 

 

 

 

SUBSTANCE TYPE

AGE OF

 

YEARS IN

DAYS IN

DAYS SINCE

 

 

 

AMOUNT

ROUTE OF ADMINISTRATION

Include all use in last 30 days.

1ST USE

 

LIFETIME

PAST 30

LAST USE

 

 

 

 

 

 

 

 

 

 

□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV

 

 

 

 

 

 

 

□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV

PHYSICAL

V.CURRENT MEDICAL CONDITIONS (Check all that apply)

□ Pregnant

Due date:

 

Prenatal care:

 

 

□ None Reported

□ Congestive Heart Failure

□ Asthma

□ Seizure

□ Cancer

□ Underweight

□ High Blood Pressure

□ Stroke

□ Emphysema

□ Cirrhosis

□ Chronic Pain

□ Overweight

□ Heart Disease

□ Diabetes

□ Epilepsy

□ Digestive Problems

□ Thyroid Disease

□ Sexually Transmitted Dz.

□ Other/Describe:

 

VI.

CURRENT & PAST MEDICATIONS(Including non-psychotropic medications)

 

 

 

 

 

 

 

Medication Name

Dose

 

Freq.

Route

Current

 

COMMENTS (Reason Prescribed/Response, etc.)

 

 

 

 

 

 

 

 

□ Yes; □ No

 

 

 

 

 

 

 

 

 

 

□ Yes; □ No

 

 

 

 

 

 

 

 

 

 

□ Yes; □ No

 

 

 

 

 

 

 

 

 

 

□ Yes; □ No

 

 

 

 

VII.

ALLERGIES

 

 

□ No

Reported Drug

or Food Allergies;

□ Other/Describe:

 

1915(c) IA v.2 (5/7/2014)

Page 1 of 4

1915(C) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT

VIII.

PRIMARY CARE PHYSICIAN

NAME

PHONE

 

FAX

 

 

 

 

 

 

IX.

ADDITIONAL SIGNIFICANT MEDICAL HISTORY (Diagnosis, Hospitalizations, Surgery, labs values, status of conditions, etc.)

 

 

 

 

 

 

 

SOCIAL

X.LEGAL STATUS

Current Legal Status: □ None; □ Probation; □ Charges Pending; □ DCFS;

□OJJ; □ Other

Comment/Detail:

Past Legal Status: □ None; □ DCFS; □ OJJ; □ Other

Comment/Detail:

 

XI.

FAMILY HISTORY (relationship status with relatives, family involvement in treatment, and living status of significant relatives):

 

 

 

 

Custodial Status: □ Independent Adult; □ Biologic Father; □ Biologic Mother; □ Joint Biologic Parents; □ Gov’t/Judicial; □ Other:

 

 

 

 

 

 

Adverse Circumstances in Family of Origin:

□ N/A; □ Poverty; □ Criminal Behavioral; □ Mental Illness; □ Substance Use; □ Abuse; □ Neglect;

 

 

 

 

□ Domestic Violence; □ Violence; □ Trauma; □ Other/Describe:

 

Summarize family history and child-rearing practices:

XII.

TRAUMA HISTORY

History of Trauma: □ None; □ Experienced; □ Witnessed; □ Abuse; □ Neglect; □ Violence; □ Sexual Assault;

□Other/Describe:

Summarize trauma history:

XIII.

LIVING SITUATION (Current status and functioning)

a.Primary Residence: □ Parent/Guardian Home; □ Relative’s Home; □ Out of Home placement; □ Homeless; □ Other/Describe:

How long at current residence? Family/Household Composition:

b.Summarize current living situation:

 

XIV.

EDUCATIONAL/EMPLOYMENT STATUS

 

 

 

a.

Current Educational Placement/Employer:

 

 

 

Current or Highest Grade Completed/Degree:

 

 

 

 

Difficulties with Reading/Writing: □ No; □ Yes;

Estimated Literacy Level:

 

b. Summarize educational history and status:

.

XV.

SOCIAL HISTORY AND COMMUNITY INTEGRATION

a.Current status and functioning (Involvement in the community, social supports and activities, social barriers)

Does Client/Member feel supported by friends or family? □ Yes; □ No;

Recreational Activities: Self-Help Activities:

b.Summarize social and community involvement:

CURRENT STATUS

XVI.

MENTAL STATUS EXAMINATION

 

(Circle or Check all that apply.)

 

 

 

a. GENERAL APPEARANCE

□ Healthy; □As stated Age;

□ Older Than Stated Age; □ Young-looking;

□ Tattoos;

□ Disheveled; □ Unkempt;

 

□ Malodorous; □ Thin;

□ Overweight;

□Obese; □ Other/Describe:

 

 

 

b. BEHAVIOR & PSYCHOMOTOR ACTIVITY

□ Normal;

□ Overactive; □ Hypoactive;

□ Catatonia;

□ Tremor;

□ Tics; □ Combative;

 

□ Other/Describe:

 

 

 

 

 

 

c.

ATTITUDE □ Optimal;

□ Constructive; □ Motivated;

□ Obstructive; □ Adversarial;

□ Inaccessible;

□ Cooperative; □ Seductive; □ Defensive;

 

1915(c) IA v.2 (5/7/2014)

 

 

 

 

Page 2 of 4

1915(C) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT

 

□ Hostile;

□ Guarded;

□ Apathetic;

□ Evasive;

□ Other/Explain:

 

 

 

 

 

 

 

 

d. SPEECH

□ Normal;

□ Spontaneous; □ Slow;

□ Impoverished;

□ Hesitant; □ Monotonous;

□ Soft/Whispered; □ Mumbled; □ Rapid;

 

□ Pressured; □ Verbose; □ Loud; □ Slurred; □ Impediment;

□ Other/Describe:

 

 

 

 

 

e.

MOOD:

□ Dysphoric;

□ Euthymic;

□ Expansive; □ Irritable;

□ Labile;

□ Elevated; □ Euphoric;

□ Ecstatic; □ Depressed; □ Grief/mourning;

 

□ Alexithymic; □ Elated;

□ Hypomanic;

□ Manic; □ Anxious; □ Tense;

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

f.

AFFECT

□ Appropriate;

□ Inappropriate; □ Blunted; □ Restricted;

□ Flat; □ Labile;

□ Tearful; □ Intense;

□ Other/Describe:

 

 

 

 

 

 

 

g. PERCEPTUAL DISTURBANCES □ None;

Hallucinations:

□ Auditory;

□ Visual;

□ Olfactory;

□ Tactile;

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. THOUGHT PROCESS

□ Logical/Coherent;

□ Incomprehensible;

□ Incoherent;

□ Flight of Ideas;

□ Loose Associations; □ Tangential;

 

□ Circumstantial;

□ Rambling;

□ Evasive;

□ Racing Thoughts;

□ Perseveration;

□ Thought Blocking;

□ Concrete;

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i. THOUGHT CONTENT

 

□ Preoccupations;

□ Obsessions;

□ Compulsions;

□ Phobias;

□ Delusions;

□ Thought Broadcasting;

 

□ Thought Insertion;

□ Thought Withdrawal; □ Ideas of Reference;

□ Ideas of Influence;

□ Delusions;

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j. SUICIDAL/HOMICIDAL IDEATION □ Suicidal Thoughts; □ Suicidal Attempts; □ Suicidal Intent; □ Suicidal Plans; □ History of Self-Injurious Behavior

 

 

□ Homicidal Thoughts; □ Homicidal Attempts;

□ Homicidal Intent;

□ Homicidal Plans;

 

 

 

 

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k. SENSORIUM/COGNITION

□ Alert;

□ Lethargic; □ Somnolent;

□ Stuporous;

Oriented to: □ Person; □ Place; □ Time;

□ Situation;

 

 

□ Normal Concentration; □ Impaired Concentration;

□ Other/Describe:

 

 

 

 

 

 

 

 

l. MEMORY

Remote Memory: □ Normal; □ Impaired;

Recent Memory: □ Normal; □ Impaired; Immediate Recall:

□ Normal;

□ Impaired

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

m. INTELLECTUAL FUNCTIONING (Estimate) □ Above Avg.; □ Normal/Avg.; □ Borderline;

Mental Retardation: □ Mild; □ Moderate;

□ Severe

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n. JUDGMENT

□ Critical Judgment Intact; □ Impaired Judgment;

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o. INSIGHT

□ True Emotional Insight;

□ Intellectual Insight; □ Some Awareness of Illness/symptoms; □ Impaired Insight; □ Denial;

 

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p. IMPULSE CONTROL □ Able to Resist Impulses;

□ Recent Impulsive Behavior; □ Impaired Impulse Control; □ Compulsions;

 

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XVII.

RISK ASSESSMENT: Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use,

 

 

 

 

 

criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc.

 

 

 

 

 

a.

a. Risk of Harm to Self:

□ Prior Suicide Attempt;

□ Stated Plan/Intent; □ Access to means (weapons, pills, etc.);

□ Recent Loss;

 

 

 

□ Presence of Behavioral Cues (isolation, giving away possessions, rapid mood swings, etc.);

□ Family History of Suicide; □ Terminal Illness;

 

 

 

□ Substance Abuse; □ Marked lack of support; □ Psychosis;

□ Suicide of friend/acquaintance; □ Other/Describe:

 

 

 

 

 

 

b.

b. Risk of Harm to Others: □ Prior acts of violence; □ Destruction of property; □ Arrests for violence; □ Access to means (weapons);

 

 

 

□ Substance use; □ Physically abused as child; □ Was physically abusive as a child; □ Harms animals; □ Fire setting;

□ Angry mood/agitation;

 

 

 

□ Prior hospitalizations for danger to others; □ Psychosis/command hallucinations;

 

 

 

 

 

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Client/Member Safety & Other Risk Factors: □ Feels unsafe in current living environment; □ Feels currently being

 

 

 

 

 

 

 

harmed/hurt/abused/threatened by someone; □ Engages in dangerous sexual behavior; □ Past involvement with Child or Adult Protective

 

 

 

Services; □ Relapse/decompensation triggers;

 

 

 

 

 

 

 

 

 

 

 

 

□ Other/Describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

□ Inappropriate sexual behaviors

□ Sex offender status

□ Pending sex offense charge

□ Report or Investigation □ Other: _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e.

Additional Risk Factors

 

 

 

 

 

 

 

 

 

 

 

 

f.Describe recipient’s preferences and desires for addressing risk factors, including any Mental Health Advance Directives or plan of response to periods of decompensation/relapse (Ex. Resources recipient feels comfortable reaching out to for assistance in a crisis.):

XVIII. CULTURAL AND LANGUAGE PREFERENCES (Language, Customs/Values/Preferences)

a.Spiritual Beliefs/Preferences:

b.Cultural Beliefs/Preferences:

1915(c) IA v.2 (5/7/2014)

Page 3 of 4

1915(C) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT

 

XIX.

PRINCIPAL DIAGNOSES

 

 

 

AXIS I

 

 

 

 

 

 

 

 

 

 

 

AXIS II

 

 

 

 

 

 

 

 

 

 

 

AXIS III

 

 

 

 

 

 

 

 

 

 

 

AXIS IV

 

 

 

 

 

 

 

 

 

 

 

AXIS V

 

Current:

Highest Past Year:

 

XX.INTERPRETIVE SUMMARY: Briefly describe client/member’s global preferences/hopes for recovery, your clinical summary, and recommended treatments/assessments, level of care, duration.

a. Recommended Services: (Check all that apply.)

□ Family Therapy; □ Individual Therapy; □ Group Therapy; □ Alcohol/Drug Assessment;

Alcohol/ Drug Individual Therapy;

□ PSR;

□ CPST; □ Other/Describe:

b.Other Services/Linkages Needed: □ Vocational Services; □ Social Services; □ Educational Services; □ Medical Services/PCP; □ Self help Groups; □ Other/Describe:

c.Additional Comments:

SIGNATURE

PRINTED NAME OF ASSESSOR

SIGNATURE

LMHP STATUS

DATE

1915(c) IA v.2 (5/7/2014)

Page 4 of 4

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