*TEMPLATE* Assessment

.. Brief Intake: .. Type of Service: [text name="variable_1" default="90791"] Initial Evaluation/Intake. Biopsychosocial Assessment. [text name="variable_1" default="Name: "] | Age: [text name="variable_1" default="y/o"]DOB [date name="variable_1" default="12/30/2019"]
::::::::: CHIEF COMPLAINT ::::::::
- Reason for referral, presenting problem: [textarea name="variable_1" default="sample text"]
referred by 
[select name="variable_1" value="beacon health| other"]
[var name="Name:"] is a [var name="y/o"] [select name="gender" value="male|female|choice C"] who is seen today as a new patient with concerns of: 
[link url="https://www.soapnote.org" memo="Chief Complaint: "]
[link url="https://www.soapnote.org" memo="Sx Assessment"]
[link url="https://www.soapnote.org" memo="Strengths "]
HPI:  
[textarea name="variable_1" default="History and Onset of Presenting Problem: "]
[link url="https://www.soapnote.org" memo="Relevant Factors"]
[link url="https://www.soapnote.org" memo="Psych Hx"]
[link url="https://www.soapnote.org" memo="Trauma Hx"]
[link url="https://www.soapnote.org" memo="SUD Hx"]
[link url="https://www.soapnote.org" memo="Medical Hx"]
Socioeconomic
[link url="https://www.soapnote.org" memo="Current Living Situation"]
[link url="https://www.soapnote.org" memo="Education/Employment Hx"]
[link url="https://www.soapnote.org" memo="Family Hx "]
[textarea name="variable_1" default="Developmental & family history as it relates to the presenting issue: "]
[link url="https://www.soapnote.org" memo="Relationship Hx"]
[link url="https://www.soapnote.org" memo="Legal Hx"]
[link url="https://www.soapnote.org" memo="Risk Assessment"]
[link url="https://www.soapnote.org" memo="MSE"]

[link url="https://www.soapnote.org" memo="Med. Necessity"]



[textarea name="variable_1" default="Current family information as it relates to presenting issue: "]
[link url="https://www.soapnote.org" memo="Current Symptoms, Stressors and Behaviors"]

Daily Activities
[textarea name="variable_1" default=" (how does client spend their day and are they able to attend to activities of daily living?): "]
Cultural & Linguistic factors: 
[textarea name="variable_1" default="sample text"]
Relationships 
[textarea name="variable_1" default="sample text"]

Family Relationships[textarea name="variable_1" default="sample text"]
Family of Origin: [textarea name="variable_1" default="sample text"]
Immediate Family: [textarea name="variable_1" default="sample text"]
Support Network: [textarea name="variable_1" default="sample text"]
History of Trauma/Exposure to Trauma: [textarea name="variable_1" default="sample text"]
Legal (include conservatorship, probation, family court, litigation, etc. if applicable):[textarea name="variable_1" default="sample text"]
Spiritual Factors:[textarea name="variable_1" default="sample text"]
Psychiatric History[textarea name="variable_1" default="sample text"]
[1] - Has client participated in counseling/psychotherapy services in the past? 
- if YES, please describe...
Provider:
Treatment Date Range (start/end date):
Therapeutic Modalities: 
Response to Treatment:
Psychiatric Hospitalizations:
[textarea name="variable_1" default="sample text"]
 Information from Other Source of Clinical Data:  [textarea name="variable_1" default="sample text"]
[2] - Has client participated in psychiatric/medication management services in the past?
f YES, please describe
when, 
with whom, 
and experience: 
[textarea name="variable_1" default="sample text"]
 - if YES, please specify
medication name
 dosage,
what the medication is for
and prescribing provider: 
[textarea name="variable_1" default="sample text"]
| Current Risks |
[textarea name="variable_1" default="sample text"]
No risks present at time of intake. 
Does client have a history of Trauma/Exposure to Trauma?



Yes
Unknown at this time
This writer rendered risk assessment for S/I and H/I; client denied
unable to specify plans, means, motivation, intent; client described content associated with future and goals associated with establishing positive and meaningful interpersonal relationships in their community.
| Medical History |
current physical condition/illness: 
primary care physician (name, address, phone): 
if child/adolescent, describe developmental history and/or prenatal/perinatal events:
| Medications |
actively taking medication at this time? 
 if YES, please specify...
medication name: 
 start & end date of medication
 (ie., Fall 2012 - Present): 
reason for Use: 
amount/dosage: 
frequency: 
Allergies to Medication or Adverse Reactions? (must specify Yes/No): 
Medical Necessity: Level of Functioning, and Functional Capacity
YES
- [1]. Is client's impairment in functional capacity the result of a mental/emotional disturbance? (Yes/No): 
- [2]. Does client's mental/emotional disturbance significantly impair their functional capacity within an important area of life functioning? (Yes/No): 
- [3]. Does client's mental/emotional disturbance create for the probability of significant deterioration in an important area of life functioning? (Yes/No): 
- [4]. Does client's mental/emotional disturbance create for the probability that the child/youth will not progress developmentally as individually appropriate? (Yes/No/Not Applicable): 
- [5]. Is client's mental/emotional disturbance a condition which specialty mental health services could correct or ameliorate? (Yes/No): 
- [6]. Given the nature of the functional impairment noted above, treatment services will significantly reduce and/or prevent significant deterioration in functioning, and because of that, the following domain/domains of functioning will be treated:
Home and Living Situation[textarea name="variable_1" default="sample text"]
Social/Peer and Interpersonal Relationships[textarea name="variable_1" default="sample text"]
Work/Occupation[textarea name="variable_1" default="sample text"]
School[textarea name="variable_1" default="sample text"]
Daily Activities[textarea name="variable_1" default="sample text"]
Financial[textarea name="variable_1" default="sample text"]
Health/Medical[textarea name="variable_1" default="sample text"]
Family Relationships[textarea name="variable_1" default="sample text"]
Legal & Safety[textarea name="variable_1" default="sample text"]
Potential for Exploitations[textarea name="variable_1" default="sample text"]
Cultural Components[textarea name="variable_1" default="sample text"]
Psychosocial Factors[textarea name="variable_1" default="sample text"]
Current living situation: [textarea name="variable_1" default="sample text"]
Vocational (include current employment status): [textarea name="variable_1" default="sample text"]
Educational Attainment, include highest level of education completed: [textarea name="variable_1" default="sample text"]





- Onset, duration:
[textarea name="variable_1" default="sample text"]
- Presenting symptoms, behaviors: [textarea name="variable_1" default="sample text"]
:::::::::::::::::::: HISTORY ::::::::::::::::::::
- History of presenting problem: [textarea name="variable_1" default="sample text"]
- Pt’s perception of cause:[textarea name="variable_1" default="sample text"]
- Family perception of cause:[textarea name="variable_1" default="sample text"]
Relevant Factors:[textarea name="variable_1" default="sample text"]
- Environment (School/Home):[textarea name="variable_1" default="- Relationships (Loss/Separation):/n- Traumatic Events:\n- Physical Abuse:\n- Sleep Patterns:\n- Eating Patterns:\n- Hygiene:\n- Peer/Colleague problems/challenges:\n- School/Work problems/challenges:\n- Additional factors (ie., MR, LD, PDD, ADD, Disruptive Behavior, Feeding, Eating, Tic, Communication,Elimination, Schiz/Psychotic, Mood, Anxiety, Neurological):Additional Areas of Concern, Associated Behaviors:"]

- Other:[textarea name="variable_1" default="sample text"]
::::: PRIOR MENTAL HEALTH HISTORY ::::[textarea name="variable_1" default="sample text"]
- Suicidality:
Homicidality
- Medications (dosage, response, adverse reactions):
- Response to treatment:
Past Interventions, Response
Parent/Child satisfaction:
- Recommendations:
-Response to Treatment
::::::::::: MEDICAL HISTORY :::::::::[textarea name="variable_1" default="sample text"]
- Illness (acute/chronic):
- Medications:
- Allergies:
- Accidents:
- Head Injuries:
- Seizures:
- Pregnancy:
- STD’s:
- HIV:
- Vaccinations:
- Hospitalizations/Surgeries:
- Vision:
- Hearing:
- Dental Health (last exam):
Pediatrician Name:
Last Physical Exam Date:[textarea name="variable_1" default="sample text"]
Environmental stressors: placements, 
Environmental stressors: Multiple Moves While Growing Up
Environmental stressors: change in famcomposition, socio-economic status, lifestyle, 
Environmental stressors: exposure to fam conflict/violence, 
Environmental stressors: major illness, 
Environmental stressors:  loss of fam/friends, 
Environmental stressors: loss/separation
Environmental Stressors: Change in School 
Environmental stressors: abuse,[textarea name="variable_1" default="sample text"]
::::: DEVELOPMENTAL HISTORY :::::[textarea name="variable_1" default="sample text"]
- Prenatal Care:- Term (Months):- Birth Weight:- Type of Delivery:- Duration of Labor:- Place of Delivery:- Post Partum Complications:
- Age of Mother:
- Age of Father:
- Marital Status:
- Did mother use alcohol, cigarettes, drugs? Specify:[textarea name="variable_1" default="sample text"]
- Illness, accidents, stressors during pregnancy:- Additional Comments and Notes:[textarea name="variable_1" default="sample text"]
:::::::::: DEVELOPMENTAL MILESTONES & ENVIRONMENTALSTRESSORS ::::::::::
1) INFANCY (age 0-3):- Motor (sit, crawl, walk):- Speech:- Eat, Sleep:- Toilet Training Experience:- Coordination:- Temperament:- Separation/Attachment:- Environmental Stressors:[textarea name="variable_1" default="sample text"]
2) EARLY YEARS (age 4-6)- Social Adjustment:- Separation:- Sexual Behaviors:- Self-Care:- Environmental Stressors:[textarea name="variable_1" default="sample text"]
3) LATENCY (age 6-11)- School Adjustment:- Peer Relationships:- Adult Relationships:- Interests/Hobbies:- Impulse Control:- Self-Care Capacities:- Environmental Stressors:
4) ADOLESCENCE (age 12 and onward)- Separation, Individuation:- Sexual Identity, Behavior:- Relationships:- Independent Functioning:- Moral Development:- Environmental Stressors:
[textarea name="variable_1" default="sample text"]
:::::::: SCHOOL HISTORY :::::::
[textarea name="variable_1" default="sample text"]- School:
- Academic Performance:
- School Changes (age, grade):
- Grade Retention:
- Attitude/Behavior:
- Attendance/Truancy:
- Suspension:
- Special Education:
- Special Classes:
- Current/Past IEP, Date:- 504 Plan:
[textarea name="variable_1" default="sample text"]
:::: JUVENILE COURT HISTORY ::::
- Arrests, Offenses:
- Tickets, Warnings
- Probation, Stipulations (current, prior)
 Incarceration:- Placement:
- Nature of Abuse:
- Age of Occurrence:
- Offender:
- Community Agency Intervention:
:: CHILD ABUSE, PROTECTIVE SERVICE HISTORY ::
- Dependency Court or Criminal Court action:
- Child Response:
- Parent Response to Disclosure:
- Placement and Type:
[textarea name="variable_1" default="sample text"]
::: FAMILY COMPOSITION :::
- Marital Status:
- Siblings:
- Half-Siblings:
- Maternal Grandparents:
- Paternal Grandparents:
- Ethnicity, Culture:
- Education:
- Occupation:
[textarea name="variable_1" default="sample text"]
::::::: FAMILY HISTORY :::::::
1) Bio Father’s Side:[textarea name="variable_1" default="sample text"]
- Medical:
- Psychiatric:
- Alcohol:
- Drugs:
- Legal, Criminal:
2) Bio Mother’s Side:[textarea name="variable_1" default="sample text"]
- Medical:
- Psychiatric:
- Alcohol:
- Drugs:
- Legal, Criminal:
3) Family Relationships:
- Current relational style:
- Disciplinary Style:
- Conflict, Violence:
[textarea name="variable_1" default="sample text"]
4) Family Strengths:- Family Strengths and Attributes:
[textarea name="variable_1" default="sample text"]
:::: FAMILY, CLIENT REFLECTIONS :::
[textarea name="variable_1" default="sample text"]- What is family/parent expecting of services:- What is client expecting of services:- What is family/parent willing to contribute (motivation):
::::::::::::::::::: END ::::::::::::::::::::