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Initial
Evaluation
|
Strengths
|-
Reason
Problem:
-
Onset
Issue:
Symptoms,
Functioning,
Capacity
[1].
Client
Impairment
Mental/Emotional
Disturbance?
(Yes/No):
[2].
Significantly
Impair
Within
Functioning?
[3].
Probability
Deterioration
[4].
Child/Youth
Developmentally
Individually
(Yes/No/Not
Applicable):
[5].
Specialty
Correct
Ameliorate?
[6].
Given
Nature
Noted
Above,
That,
Domain/Domains
Treated:
[
]
Home
Yes
Social/Peer
Relationships
Work/Occupation
Health/Medical
&
Potential
Exploitations
Situation:
Attainment,
Highest
Completed:
Status):
(How
Living?):
Factors:
---
------
Origin:
Family:
Social/Friend
Relationships:
Network:
Trauma/Exposure
Trauma:
Conservatorship,
Court,
Litigation,
[1]
Participated
Counseling/Psychotherapy
Past?
Yes,
Please
Describe...
Provider:
Range
(Start/End
Date):
Therapeutic
Modalities:
Treatment:
Hospitalizations:
Source
Data:
[2]
Psychiatric/Medication
When,
Whom,
Experience:
Specify
Name,
Dosage,
For,
Prescribing
Trauma?
(Yes/No/Unknown
Time):
Rendered
S/I
H/I;
Denied,
Plans,
Means,
Intent;
Described
Content
Meaningful
Condition/Illness:
Primary
Physician
(Name,
Address,
Phone):
Child/Adolescent,
Prenatal/Perinatal
Events:
Time?
Specify...
Name:
End
(Ie.,
Fall
2012
Present):
Use:
Amount/Dosage:
Frequency:
Adverse
Reactions?
(Must
Yes/No):
Types
Include,
To:
Amphetamines,
Cocaine,
Opiates,
Sedatives,
Pcp,
Hallucinogens,
Inhalants,
Marijuana,
Nicotine,
Rx
Drugs.
Using
Substances?
Type:
Onset:
Dosage/Amount:
Action
Required?
Impacting
Health?
}
intervention.
addition,
reviewed,
explained,
Materials,
Practices,
Confidentiality,
Resolution,
Directives,
List,
Cultural/Linguistic
reviewed.
information.
form,
List.
make
’s
assistance.

CPS,
support,
she
worker.
made,
way.
tracking.
task.
techniques,
self-soothing
exercises,
outs
introduced.
“time-outs”
needed.
activities.
Communication,
coordination,
’s
,
therapist,
manager,
(who
person/people)
members,
providers,
educators,
(i.e.,
accessing,
way)
made.
development,
livi
placement.
Pre-placement
visit(s)
follow-up
obtained.
symptoms.
accommodations.
(ADLs)
decisions)
wishes
morning,
transportation,
aids)
accomplish.
chores)
symptoms/problem
changes,
medication)
store)
person/people
plan(s)
(if
present,
Collateral.
(with
Information)
obstacles,
(and
hinder)
functioning.
well,
Self,
Others,
disability.
group;
providing
Management,
(depends
activity)
¾
/parents,
etc.
solutions/ways
/’s
Facilitated…for
cues/prompts
limits/boundaries
time/
variety
settings.
others/peers
community.
to…
redirection.
______
meeting…
…to
goals/plan.
/hygiene/
safety/the
education…
problem-solving
regarding…
staff’s
arrival,
/seemed/
…describe
qualifyingstatement
i.e.
affect,
/demeanor,
talkative,
specific,
enforcement,
probation,
(when
what)
(CWS)
Guardian/Administrator’s
(prescribed
over-the-counter)
medication,
frequency.
(to
food,
seasonal,
etc.)
children,
history,
age,
disheveled,
clean,
neat,
appearance,
etc)
overactive,
active,
fidgety,
distant,
(for
adult),
friendly,
impulsive,
cooperative,
uncooperative,
evasive,
gestures,
tics,
grimacing,
61
slumped,
relaxed,
stooped,
soft,
coherent,
incoherent,
rambling,
pressured,
appropriate,
rich,
flat,
restricted,
blunted,
euthymic,
depressed,
elevated,
illusions,
paranoia,
grandiosity,
hallucinations,
delusions,
person,
place,
time)
remote,
recent,
immediate,
nightmares,
frequently,
asleep,
little,
deal)
intervention;
?
progress,
why.
4
services.
services,
plan.
Min.
illness,
(SADVC)
place.
changes.
decompensation.
caregiver,
classroom)
(Be
possible.
goals.)
events/stress
(physical,
sexual,
emotional).
issues)
stressors,
factors,
conditions,
job/employment/educational
begin?)
child’s
assessment,
behaviors.
agression
spending
suicidal/homicidal
ideation.
store.
paperwork.
9
female,
sleeping,
(Approx.
month),
family.
answer,
intake.
hair.
ago,
class,
falling.
spells.
;
question.
divorced;
years.
sx,
attempts.
Currently,
hypersomnia,
appetite,
concentrating,
memory,
H/I.
YCADMH
regularly.
behaviors,
school,
sister.
year,
goals.
(e.g.,
lecturing,
homework,
class)
student.
year.
self-blaming
attack.
tasks.
impulsivity.
(include
location,
provider,
date,
care,
possible)
receive
situation/employment
caregivers).
(abuse,
neglect,
illness)
ability,
achievements,
participation,
documented.
he

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Initial
Evaluation
|
Strengths
|-
Reason
Problem:
-
Onset
Issue:
Symptoms,
Functioning,
Capacity
[1].
Client
Impairment
Mental/Emotional
Disturbance?
(Yes/No):
[2].
Significantly
Impair
Within
Functioning?
[3].
Probability
Deterioration
[4].
Child/Youth
Developmentally
Individually
(Yes/No/Not
Applicable):
[5].
Specialty
Correct
Ameliorate?
[6].
Given
Nature
Noted
Above,
That,
Domain/Domains
Treated:
[
]
Home
Yes
Social/Peer
Relationships
Work/Occupation
Health/Medical
&
Potential
Exploitations
Situation:
Attainment,
Highest
Completed:
Status):
(How
Living?):
Factors:
---
------
Origin:
Family:
Social/Friend
Relationships:
Network:
Trauma/Exposure
Trauma:
Conservatorship,
Court,
Litigation,
[1]
Participated
Counseling/Psychotherapy
Past?
Yes,
Please
Describe...
Provider:
Range
(Start/End
Date):
Therapeutic
Modalities:
Treatment:
Hospitalizations:
Source
Data:
[2]
Psychiatric/Medication
When,
Whom,
Experience:
Specify
Name,
Dosage,
For,
Prescribing
Trauma?
(Yes/No/Unknown
Time):
Rendered
S/I
H/I;
Denied,
Plans,
Means,
Intent;
Described
Content
Meaningful
Condition/Illness:
Primary
Physician
(Name,
Address,
Phone):
Child/Adolescent,
Prenatal/Perinatal
Events:
Time?
Specify...
Name:
End
(Ie.,
Fall
2012
Present):
Use:
Amount/Dosage:
Frequency:
Adverse
Reactions?
(Must
Yes/No):
Types
Include,
To:
Amphetamines,
Cocaine,
Opiates,
Sedatives,
Pcp,
Hallucinogens,
Inhalants,
Marijuana,
Nicotine,
Rx
Drugs.
Using
Substances?
Type:
Onset:
Dosage/Amount:
Action
Required?
Impacting
Health?
}
intervention.
addition,
reviewed,
explained,
Materials,
Practices,
Confidentiality,
Resolution,
Directives,
List,
Cultural/Linguistic
reviewed.
information.
form,
List.
make
’s
assistance.

CPS,
support,
she
worker.
made,
way.
tracking.
task.
techniques,
self-soothing
exercises,
outs
introduced.
“time-outs”
needed.
activities.
Communication,
coordination,
’s
,
therapist,
manager,
(who
person/people)
members,
providers,
educators,
(i.e.,
accessing,
way)
made.
development,
livi
placement.
Pre-placement
visit(s)
follow-up
obtained.
symptoms.
accommodations.
(ADLs)
decisions)
wishes
morning,
transportation,
aids)
accomplish.
chores)
symptoms/problem
changes,
medication)
store)
person/people
plan(s)
(if
present,
Collateral.
(with
Information)
obstacles,
(and
hinder)
functioning.
well,
Self,
Others,
disability.
group;
providing
Management,
(depends
activity)
¾
/parents,
etc.
solutions/ways
/’s
Facilitated…for
cues/prompts
limits/boundaries
time/
variety
settings.
others/peers
community.
to…
redirection.
______
meeting…
…to
goals/plan.
/hygiene/
safety/the
education…
problem-solving
regarding…
staff’s
arrival,
/seemed/
…describe
qualifyingstatement
i.e.
affect,
/demeanor,
talkative,
specific,
enforcement,
probation,
(when
what)
(CWS)
Guardian/Administrator’s
(prescribed
over-the-counter)
medication,
frequency.
(to
food,
seasonal,
etc.)
children,
history,
age,
disheveled,
clean,
neat,
appearance,
etc)
overactive,
active,
fidgety,
distant,
(for
adult),
friendly,
impulsive,
cooperative,
uncooperative,
evasive,
gestures,
tics,
grimacing,
61
slumped,
relaxed,
stooped,
soft,
coherent,
incoherent,
rambling,
pressured,
appropriate,
rich,
flat,
restricted,
blunted,
euthymic,
depressed,
elevated,
illusions,
paranoia,
grandiosity,
hallucinations,
delusions,
person,
place,
time)
remote,
recent,
immediate,
nightmares,
frequently,
asleep,
little,
deal)
intervention;
?
progress,
why.
4
services.
services,
plan.
Min.
illness,
(SADVC)
place.
changes.
decompensation.
caregiver,
classroom)
(Be
possible.
goals.)
events/stress
(physical,
sexual,
emotional).
issues)
stressors,
factors,
conditions,
job/employment/educational
begin?)
child’s
assessment,
behaviors.
agression
spending
suicidal/homicidal
ideation.
store.
paperwork.
9
female,
sleeping,
(Approx.
month),
family.
answer,
intake.
hair.
ago,
class,
falling.
spells.
;
question.
divorced;
years.
sx,
attempts.
Currently,
hypersomnia,
appetite,
concentrating,
memory,
H/I.
YCADMH
regularly.
behaviors,
school,
sister.
year,
goals.
(e.g.,
lecturing,
homework,
class)
student.
year.
self-blaming
attack.
tasks.
impulsivity.
(include
location,
provider,
date,
care,
possible)
receive
situation/employment
caregivers).
(abuse,
neglect,
illness)
ability,
achievements,
participation,
documented.
he

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