San Mateo County Behavioral Health & Recovery Services WORKSHEET FOR ADULT INITIAL ASSESSMENT
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1 San Mateo County Behavioral Health & Recovery Services WORKSHEET FOR ADULT INITIAL ASSESSMENT Name MH Record# Episode DOB Sex SSN 1. Identifying & CSI Information Assessment Type (Indicates the type of staff involved in completing the assessment; Does not change the requirements; Determines the title of printed form) Assessment Date Name Client Prefers to Use Assessment Type Source of Information Initial Assessment (Clinician, Case Mgr) Client Interview Family Multidisc. Assessment (Includes MD Eval.) ICI Previous Records Physician Initial Eval. (MD/NP Only) Transfer Note SMMC Referral Source Mills-Peninsula Fremont Hospital PES/3AB HSA/Social Services Probation/Parole PCP/Health Care Stanford Hospital Referral Contact Info Language Information Primary Language of Client Client s Preferred Language Language of Family Language Assessment Conducted In Service Strategies (Check all that apply) Education (highest grade level completed) Assertive Community Treatment Dlvr d in Partnership w Health Care Dlvr d in Partnership w Law Enforcement Employment Status Dlvr d in Partnership w Social Services Dlvr d in Partnership w Sub. Abuse Serv. Ethnic Specific Service Strategy Living Arrangement Family Psychoeducation Family Support Functional Family Therapy Conservatorship/Court Status Illness Management & Recovery Integrated Dual Dx Treatment Integrated Services MH + Aging Integrated Services MH + Dev.Disability Number of children under the age Medication Management of 18 the client cares for or is Multi-systemic Therapy responsible for at least 50% of the time. New Generation Medications Peer/Family Delivered Services Number of dependent adults age 18 Psychoeducation or older the client cares for or is Supportive Education responsible for at 50% of the time. Supportive Employment Therapeutic Foster Care Unknown Service Strategy Page 1 of 10
2 2. Clinical Information Description of Current Presenting Problems (Include Referral Reason, Symptoms, Behaviors and Impairments) Mental Health History (Include Onset, Severity & Changes, Family MH Hx) Client s Strengths /Assets /Ethnic or Cultural Identity / Spiritual Factors /Positive Coping Skills Significant Developmental Issues /Childhood Events /Family History /Immigration Hx QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 2 of 10
3 Psychosocial History/ Relationships/ Education/ Employment/ Interests/ Social Activities and Supports: How does client identify their gender? How does client identify their sexual orientation? Female Male Transgender Hetero Bisexual Gay/Lesbian Intersex Decline to state Questioning Decline to state Unknown Unknown Psychiatric Hospitalization/ Partial Hospitalization History/ Residential (Include Provider & Dates) Outpatient Treatment History (Include Providers & Dates, Therapeutic Interventions & Responses) QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 3 of 10
4 Physical Medical History /Significant Illnesses /Chronic Conditions /Surgeries /Allergies Medication History (Include Medication Name, Dosage, Adverse Reactions & Response) Past /Present Criminal Justice History (Include Legal Issues, Arrests, Probation, Child Custody, DUI) Sexual History /HIV Risk (RESTRICTED) QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 4 of 10
5 3. Risk and Co-Occurring Information Risk of HARM to SELF/SUICIDAL Thoughts/Behavior Past HARM to SELF/SUICIDAL Thoughts/Behavior Yes Denied Undetermined Yes No Unknown Current HARM to OTHERS/HOMOCIDAL Thoughts Past HARM to OTHERS/HOMOCIDAL Thoughts Yes Denied Undetermined Yes No Unknown Current Domestic Violence Issues Past Domestic Violence Issues Yes No Unknown Yes No Unknown Engaged in Violent Acts? (Physical, Sexual, Vandalism) Victim of Violence? Yes No Unknown Yes No Unknown Access to FIREARMS/WEAPONS Does SUBSTANCE USE Impact Risk? Yes Denied Undetermined Yes No Unknown Substance Use Issues Impacting Client (Select 1 or more) Current Substance Abuse Use Impacts Functioning/Presenting Problem Abuse/Misuse of Prescription Drugs Abuse/Misuse of Caffeine None Unknown Past Substance Abuse History Abuse/Misuse of OTC Medications Use of Illicit Drugs Abuse/Misuse of Nicotine Trauma History (Select 1 or more.) Physical Abuse Sexual Abuse Assault Domestic Violence Military Combat Torture Immigration/Displacement Separation Suspected Unknown None Risk Evaluation/Trauma Info (Include PTSD Symptoms) /AOD Use (Drug Name, Frequency, Age of 1 st Use, Date of last use.) QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 5 of 10
6 4. LOCUS 1. Risk of Harm 1-Minimal Risk 2-Low Risk 3-Moderate Risk 4-Serious Risk 5-Extreme Risk 2. Functional Status 1-Mimimal 2-Mild 3-Moderate 4-Serious 5-Severe 3. Medical, Addictive and Psychiatric Co-Morbidity 1-None 2-Minor 3-Significant 4-Major 5-Severe 4a. Environmental Stressors 1-Low Stress 2-Mild 3-Moderate 4-High 5-Extreme Stress 4b. Environmental Support 1-Highly Supportive 2-Supportive 3-Limited 4-Minimal 5-No Support 5. Treatment and Recovery 1-Fully 2-Significant 3-Moderate/Equivocal 4-Poor 5-Negligible 6. Engagement 1-Optimal 2-Positive 3-Limited 4-Minimal 5-Unengaged 5. Mental Status Exam Calculate LOCUS Score Total Score May ONLY be completed by Licensed/Waivered MD/NP, MFT/MFTI, LCSW/ASW, Psy (PhD/PyD), RN with Psych MS or Trainee with co-signature. General Appearance Thought Content and Process Appropriate Disheveled Bizarre Within Normal Limits Auditory Hallucinations Inappropriate Visual Hallucinations Delusions Affect Paranoid Ideation Bizarre Within Normal Limits Constricted Suicidal Ideation Homicidal Ideation Blunted Flat Flight of Ideas Loose Associations Angry Sad Poor insight Attention Issues Anxious Labile Fund of Knowledge Inappropriate Speech Physical and Motor Within Normal Limits Circumstantial Within Normal Limits Hyperactive Tangential Pressured Agitated Motor Retardation Slowed Loud Tremors/Tics Unusual Gait Muscle Tone Issues Cognition Mood Within Normal Limits Orientation Within Normal Limits Depressed Memory Problems Impulse Control Anxious Expansive Poor Concentration Poor Judgment Irritable MSE Info QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 6 of 10
7 6. Diagnosis May ONLY be completed by Licensed/Waivered MD/NP, MFT/MFTI, LCSW/ASW, Psy (PhD/PyD), RN with Psych MS or Trainee with co-signature. Type of Diagnosis Trauma (CSI) Admission Discharge Update Yes No Unknown Original Date of this Dx (Change if ANY Dx Change) Has Substance Abuse/Dependence Diagnosis (CSI) Yes No Unknown Time of Diagnosis Substance Abuse/Dependence Diagnosis (CSI) Diagnosing Practitioner Name/ID Number Unique Practitioner ID AXIS I Diagnosis AXIS II AXIS I -1 (Primary Diagnosis) AXIS II 1 AXIS I -2 AXIS II 2 AXIS III Medical Conditions Allergies Anemia Arterial Sclerotic Disease Arthritis Asthma Birth Defects Blind/Visually Impaired Cancer Carpal Tunnel Syndrome Chronic Pain Cirrhosis Cystic Fibrosis Deaf/Hearing Impaired Diabetes Digestive Disorders (Reflux, IBS) Ear Infections Epilepsy/Seizures Heart Disease Hepatitis Hypercholesterolemia Hyperlipidemia Hypertension Hyperthyroid Infertility Migraines Multiple Sclerosis Muscular Dystrophy No General Medical Condition Obesity Osteoporosis Parkinson s Disease Physical Disability Psoriasis AXIS IV Psychosocial and Environmental Problems Problems with Primary Support Group Problems related to social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care Problems related to legal system/crime psychosocial/environment problems Axis V GAF Do not change unless the Primary Dx is an Axis II Dx. Do not make substance abuse Dx Primary unless there is no other Dx. Primary Diagnosis QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 7 of 10
8 Sexually Transmitted Disease (STD) Stroke Tinnitus Ulcers Unknown/Not Reported General Medical Condition Diagnosis Comments QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 8 of 10
9 7. Clinical Formulation/Medical Necessity May ONLY be completed by Licensed/Waivered MD/NP, MFT/MFTI, LCSW/ASW, Psy (PhD/PyD), RN with Psych MS or Trainee with co-signature. As a result of the Primary Diagnosis, the client has the following functional impairments: Treatment is being provided to address, or prevent, significant deterioration in an important area of life functioning School/Work Functioning Social Relationships Daily Living Skills Ability to Maintain Placement Symptom Management Clinical Formulation/Summary: Additional Factors or Comments QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 9 of 10
10 8. Finalize Indicate other staff contributing to this assessment. Contributing Practitioner Contributing Practitioner Area of Contribution Area of Contribution Send To Send To Outgoing Comments Draft/Pending Approval/Final Draft Final Pending Approval QI-Clinical Forms\Assessments\NotesForAdultInitialAssessment2.13 Page 10 of 10
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