CSSD Evaluation Report

Client Name: [text name="cxName" default=""]
Date of Report: [date name="rptDate" default=""]
[comment memo="(marital)
(race) 
(sexuality) 
(gender) 
(sex)"]
[textarea name="intro" default="Client is a _ year old  with a history of (legal/mh/sa) currently treated with _______ who presents for initial evaluation per recommendation from (referal source)."]  

PRESENTING SYMPTOMS
[textarea name="sx" default="Client reports current symptoms of ___.  These symptoms have been going on since ___. They decided to seek treatment because/following ___."]
 
PAST PSYCHIATRIC HISTORY
[comment memo="Hospitalizations? 
	Past meds
	Med compliance
	OP treatment
	Past SI/HI/AVH
        Violence"]
[textarea name="psychhx" default="Client was diagnosed with ___ in ____(year). (Describe precipitating events.) client reports/denies previous hospitalizations _(details). Client has been treated in the past with _(rx)___ with __ effects."]

PAST MEDICAL HISTORY
[comment memo="Seizures?
	Head injury w/LOC?
	Surgical history
	Medications
	Allergies
	STDs
	Pregnant?"]
[textarea name="PMH" default="Client denies/mentions diagnosis of the following medical conditions: ____. Client is allergic to _/denies known allergies to medications."]

SUBSTANCE USE
[comment memo="Tobacco:"][textarea name="Tobacco" default="Denies" rows="1"]
[comment memo="Alcohol:"][textarea name="Alcohol" default="Denies" rows="1"]
[comment memo="Drugs:"][textarea name="Drugs" default="Denies" rows="1"]
[comment memo="Gambling:"][textarea name="gambling" default="Not asked" rows="1"]
[comment memo="Rehab:"][textarea name="Rehab" default="Not asked" rows="1"]
[comment memo="Other:"][textarea name="Other" default="Not asked" rows="1"]

DEVELOPMENTAL HISTORY
[comment memo="Place of birth:"][textarea name="Born" default="Not asked" rows="1"]
[comment memo="Raised by:"][textarea name="Raised" default="Not asked" rows="1"]
[comment memo="Parents (living/deceased, occupations, relationships):"][textarea name="Parents" default="Not asked" rows="1"]
[comment memo="Siblings (living/deceased, occupations, relationships):"][textarea name="Siblings" default="Not asked" rows="1"]
[comment memo="Other important relationships:"][textarea name="relationships" default="Not asked" rows="1"]
[comment memo="Birth trauma:"][textarea name="birthtrauma" default="Not asked" rows="1"]
[comment memo="Early Development:"][textarea name="earlydev" default="Not asked" rows="1"]
SOCIAL HISTORY
[comment memo="Marital status:"][textarea name="Marital" default="Not asked" rows="1"]
[comment memo="Children:"][textarea name="children" default="Not asked" rows="1"]
[comment memo="Relationships:"][textarea name="rltnships" default="Not asked" rows="1"]
[comment memo="Current living situation:"][textarea name="living" default="Not asked" rows="1"] 
[comment memo="Employment:"][textarea name="job" default="Not asked" rows="1"] 
[comment memo="Education:"][textarea name="school" default="Not asked" rows="1"] 
[comment memo="Military:"][textarea name="military" default="Not asked" rows="1"] 
[comment memo="Disability:"][textarea name="disability" default="Not asked" rows="1"] 
[comment memo="Legal:"][textarea name="legal" default="Not asked" rows="1"] 
[comment memo="Spiritual:"][textarea name="religion" default="Not asked" rows="1"] 

TREATMENT PLAN
[comment memo="Goals:"][textarea name="goals" default="Not asked" rows="1"] 
[comment memo="Strengths:"][textarea name="strengths" default="Not asked" rows="1"] 
[comment memo="Challenges:"][textarea name="challenges" default="Not asked" rows="1"] 
[comment memo="Areas that need improvement:"][textarea name="improvements" default="Not asked" rows="1"] 
[comment memo="Determination of the client's readiness to change:"]
Client is in the [checkbox name="stgOfChange" value="Precontemplation|Contemplation|Preparation|Action|Maintenance|Relapse"] stage of change.
[textarea name="stgChngNote" default=""] 
[comment memo="Diagnosis:"]
Client's current diagnosis is [textarea name="cxDx" default=""]
[comment memo="Recommended treatment ( what and how often):"]
It is recommended that client participate in [checkbox name="recommendations" value="comleting a psychiatric evaluation|additional assessment needed|anger management group|co-occurring group|individual counseling|intensive out patient|medically assisted treatment|medication management|mental health group|no treatment recommendations|other services outside of program|relapse prevention group|substance abuse group|trauma group"]
[textarea name="txRec" default=""]
[comment memo="Anticipated start of service (actual date):"]
Client's first individual counseling appointment is scheduled for [date name="iCounDate" default=""] at [text name="iCounTme" default="00:00"][checkbox name="iCoTmap" value="AM|PM"]
[textarea name="urinalysis" default=""]
[comment memo="Current MAT:"]
[radio name="crntMAT" value="Yes|No"]
[conditional field="crntMAT" condition="(crntMAT).is('Yes')"][textarea name="CrntMatNt" default=""][/conditional]
[comment memo="Psychiatric evaluation appointment (include date and time):"]
[date name="psychApptDt" default=""] at [text name="psychApptTm" default="00:00"][checkbox="iCoTmap" value="AM|PM"]
[textarea name="psychAppt" default=""]
Client Name:
Date of Report:
(marital)
(race)
(sexuality)
(gender)
(sex)



PRESENTING SYMPTOMS


PAST PSYCHIATRIC HISTORY
Hospitalizations?
Past meds
Med compliance
OP treatment
Past SI/HI/AVH
Violence



PAST MEDICAL HISTORY
Seizures?
Head injury w/LOC?
Surgical history
Medications
Allergies
STDs
Pregnant?



SUBSTANCE USE
Tobacco:
Alcohol:
Drugs:
Gambling:
Rehab:
Other:

DEVELOPMENTAL HISTORY
Place of birth:
Raised by:
Parents (living/deceased, occupations, relationships):
Siblings (living/deceased, occupations, relationships):
Other important relationships:
Birth trauma:
Early Development:
SOCIAL HISTORY
Marital status:
Children:
Relationships:
Current living situation:
Employment:
Education:
Military:
Disability:
Legal:
Spiritual:

TREATMENT PLAN
Goals:
Strengths:
Challenges:
Areas that need improvement:
Determination of the client's readiness to change:
Client is in the stage of change.

Diagnosis:
Client's current diagnosis is
Recommended treatment ( what and how often):
It is recommended that client participate in

Anticipated start of service (actual date):
Client's first individual counseling appointment is scheduled for at

Current MAT:


Psychiatric evaluation appointment (include date and time):
at

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.17, 85 form elements, 49 boilerplate words, 3 text boxes, 37 text areas, 3 dates, 4 checkboxes, 1 radio buttons, 36 comments, 1 conditionals, 68 total clicks
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