C Behavioral Health Form – Fill Out and Use This PDF

X.

LEGAL STATUS

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

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

□ OJJ; □ Other

Comment/Detail:

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;

□ Domes c Violence;

□ Violence; □ Trauma; □ Other/Describe:

Summarize significant CANS results:

XII.

TRAUMA HISTORY

History of Trauma: □ None; □ Experienced;

□ Witnessed;

□ Abuse; □ Neglect; □ Violence; □ Sexual Assault;

□ Other/Describe:

XIII.

LIVING SITUATION (Current status and functioning)

a.

Primary Residence: □ Parent/Guardian Home; □ Rela ve’s Home; □ Out of Home placement; □ Homeless; □ Other/Describe:

How long at current residence?

Family/Household Composition:

b. Summarize significant CANS results:

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 significant CANS results:

.

XV.

SOCIAL HISTORY AND COMMUNITY INTEGRATION

a.

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

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

Recreational Activities:

Self‐Help Activities:

b. Summarize significant CANS results:

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;

□ Ta

oos;

□ Disheveled;

□ Unkempt;

□ Malodorous; □ Thin;

□ Overweight; □Obese;

□ Other/Describe:

b. BEHAVIOR & PSYCHOMOTOR ACTIVITY

□ Normal;

□ Overac

ve;

□ Hypoac

ve;

□ Catatonia;

□ Tremor;

□ Tics;

□ Comba ve;

□ Other/Describe:

c.

ATTITUDE

□ Optimal; □ Constructive; □ Motivated;

□ Obstructive; □ Adversarial;

□ Inaccessible;

□ Cooperative;

□ Seductive;

□ Defensive;

□ 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;

□ Ecsta c;

□ Depressed;

□ Grief/mourning;

□ Alexithymic; □ Elated;

□ Hypomanic;

□ Manic; □ Anxious;

□ Tense; □ Other/Describe:

c.

AFFECT

□ Appropriate;

□ Inappropriate; □ Blunted;

□ Restricted;

□ Flat;

□ Labile;

□ Tearful;

□ Intense; □ Other/Describe:

g. PERCEPTUAL DISTURBANCES □ None;

Hallucinations:

□ Auditory;

□ Visual;

□ Olfactory;

□ Tac

le;

□ Other/Describe:

h. THOUGHT PROCESS

□ Logical/Coherent;

□ Incomprehensible;

□ Incoherent;

□ Flight of Ideas;

□ Loose Associa

ons;

□ Tangen al;

□ Circumstan al;

□ Rambling;

□ Evasive;

□ Racing Thoughts;

□ Persevera

on;

□ Thought Blocking;

□ Concrete;

□ Other/Describe:

1915(c) IA v.1 (4/2012)

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i. THOUGHT CONTENT

□ Preoccupa ons; □ Obsessions; □ Compulsions; □ Phobias;

□ Delusions; □ Thought Broadcas ng;

□ Thought Inser on;

□ Thought Withdrawal; □ Ideas of Reference; □ Ideas of Influence;

□ Delusions;

□ Other/Describe:

j. SUICIDAL/HOMICIDAL IDEATION □ Suicidal Thoughts; □ Suicidal A

empts; □ Suicidal Intent; □ Suicidal Plans; □ History of Self‐Injurious Behavior

□ Homicidal Thoughts;

□ Homicidal A empts; □ Homicidal Intent;

□ Homicidal Plans;

□ Other/Describe:

k. SENSORIUM/COGNITION

□ Alert; □ Lethargic; □ Somnolent; □ Stuporous;

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

□ Situa on;

□ Normal Concentra

on;

□ Impaired Concentra on;

□ 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. JUDGEMENT □ Cri

cal Judgment Intact; □ Impaired Judgment;

□ Other/Describe:

o. INSIGHT

□ True Emo onal 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. Risk of Harm to Self:

□ Prior Suicide A empt;

□ 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:

XVIII.

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

a.

Spiritual Beliefs/Preferences:

b.

Cultural Beliefs/Preferences:

XIX.

PRINCIPAL DIAGNOSES

AXIS I

AXIS II

AXIS III

AXIS IV

AXIS V

Current:

Highest Past Year:

XX.

INTERPRETATIVE SUMMARY Briefly describe client’s global preferences/hopes for recovery, recommended treatments/assessments, level of care,

duration.

a.

CSoC Plan of Care Services Options for Child & Family Team consideration: (Check all that apply.)

□ Family Therapy;

□ Individual Therapy; □

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

□ Parent Support/Training;

□ Youth Support/Training;

□ Crisis Stabilization; □ Respite;

□ Independent Living/Skill Building; □ PSR;

□ CPST;

□ Other/Describe:

b.

Other Services/Linkages Needed: □ Voca onal Services; □ Social Services; □ Educa onal 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.1 (4/2012)

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