Debbie Papps, LCSW, LLC 333 Lincoln St, Saco, ME 04072

Transcription

1 Debbie Papps, LCSW, LLC 333 Lincoln St, Saco, ME Comprehensive Assessment Client Information Packet Name: Date Your family information and previous treatment information is very important to us in determining the right services for you or your family member. For this reason, we are asking you to complete the following information as accurately as you can. If you need help in completing these forms, please let us know and someone will be able to assist you. Thank-you so much for providing this important information and taking the time to complete it. If further space is needed, please use the back of the page. Please complete this information for the person (yourself or your child/adolescent) who is requesting services. SOCIAL HISTORY 1. Current Living Situation: Please list the people who make up your current household (if completing for a child who moves between 2 households, identify members in both): Household Members (Name) Age Relationship Quality of Relationship Good Fair Poor Comments: 2. Check where you are presently living: House/Apartment Group Home Temporary Housing Living with a friend Homeless Homeless staying with a friend Shelter Parent/Guardian/Relative Foster care Other Comments: 3. Other Important People: Please list any additional people in your life that it would be helpful for us to know about (ie. guardian, teachers, legal representatives, important friends, extended family): Name Relationship Phone Will you sign a release? 4. If you are completing for a child with shared parental responsibilities or an adult who is under guardianship, who has the right to make legal decisions? (please provide any court documents that you

2 have to verify at your next appointment): 5. Educational History: What is the highest grade that you (or if completing for a child) completed in school? 5a. Briefly describe your (or if completing for a child) experience(s) in school (i.e. attendance, average grades, relationships with teachers, friends, suspensions or other concerns): 5b. Did you (or if completing for a child) receive any accommodations in school or have an IEP (Individualized Educational Plan)? If yes, please describe: If completing for a child, skip #6 through #7 6. Employment History: Currently: c working (full time) c working (part time) c disabled c unemployed. Usual Occupation: Longest period of continuous employment: If unemployed/disabled, when last worked: 6a. Current or past issues related to employment or relationships with supervisors: 7. Military History: Have you ever served in the military? If yes, complete below. Date/Type of Discharge: Military Branch: Any service-related Disability: 8. Current Sources of Income (Please check all that apply, if completing for a child, identify family income): c Employment c Family c TANF c Other: c Unemployment c Friends c SSI/SSDI (disability c Spouse c Child Support c No Support 10. Legal History: Any current or past legal issues? If yes, please list Legal: Arrests/Problems Current Past Probation/Parole Probation Officer Restraining Order OUI, If yes # of OUI Describe: Date of most recent:

3 11. Mental Health Treatment History: Have you ever received Mental Health services? Yes No (outpatient, hospital, partial hospital) If yes, please list current/past Mental Health Treatment. (If more room is needed please write on back) Current outpatient treatment? cyes c No If yes, please list providers Agency/ Clinician How Long? Is it helpful/comments? Past outpatient treatment? If yes, please list providers Agency/Clinician How long? Was it helpful/comments? Past psychiatric hospitalizations If yes, please list hospitalizations Hospital Year How Long? Diagnoses (if known) Was it helpful/comments? Comments: 12. Substance Use History 12a. In the last 30 days, have you used any drugs (including alcohol) other than those prescribed? Yes No If yes, specify in the grid below: 12b. Have you have you had any periods of heavy use prior to the last year? Yes No (complete all areas of the grid as applicable) Type of Drug Last used First used Amount, frequency, route, duration of current use Alcohol Yes No Marijuana Yes No Cocaine Yes No Opiates Yes No Heroin Yes No Methadone Yes No Crystal Meth Yes No Ecstasy Yes No Crack Yes No Amphetamines Yes No

4 Tranquilizers Yes No Other Substances Yes No Specify: OTC Yes No Specify: 12c. Is the above use, or use in the past year, a problem in your opinion? Yes No Explain: 12d. Is above use, or use in the past year, a problem for anyone else? Yes No Relationship 12e. Drugs used and approximate age (teens, 20 s, 30 s, ): NA 12f. Alcohol/drug-related consequences (ask and check all that apply) Seizures DT s Psychosis Depression Blackouts Tremors Other medical Legal Job School Relationship Tolerance issues Housing None Details of above: 13. Substance Abuse Treatment History: ( NA, if not applicable skip to #14): Have you ever received Substance Abuse services? No (outpatient, partial hospital, detox, rehab.) If yes, please list current/past Substance Abuse Treatment. Current outpatient treatment? cyes c No If yes, please list providers Agency/ Clinician How Long? Is it helpful/comments? Past outpatient treatment? If yes, please list providers Agency/Clinician How long? Was it helpful/comments? Past inpatient treatment? If yes, please list detox, rehabs, partial hospital Detox, rehab Year How Long? Diagnoses (if known) Was it helpful/comments?

5 Comments: 14. Family MH/SA History: Has anyone in your family experienced and/or received treatment for Psychiatric/Substance Abuse problems? If yes, please list below: Family member/significant other Psychiatric Disorder Describe: 15. Abuse/Trauma History: Do you have a history of abuse or trauma? Yes No Decline Unknown If yes, please complete: Comments: 16. Sexual History (orientation, problems, whether currently active): NA not currently active 17. Please describe any personal interests or hobbies that may help you relieve stress/relax : 18. Please identify any supports (individuals/groups/church/spiritual beliefs ) that are now or have been helpful to you in the past: 19. What is currently working well in your life? Client Signature: Date: Guardian Signature: Date: Thank-you very much for taking the time to complete this information.