Assessment-Intake

SUMMARY
[text name="cxName" default=""]
[var name="cxName"] is a [text name="cxAge" default="" size="5"] year old [select name="cxRace" value="Alaskan Native|Asian|African-American/Black|White|Hawaiian Native|Native American|Pacific Islander|Latinx|Hispanic|Non-specified Race"] [select name="cxSxlty" value="heterosexual|homosexual|bisexual|asexual|pansexual|queer|questioning|fluid"], [select name="cxGndr" value="cisgender|transgender-maleToFemale|transgender-femaleToMale|transgender-nonbinary-male|transgender-nonbinary-female"][select name="sex" value="female|intersex|male"] with a history of [checkbox name="cxHx" value="criminal justice involment|mental health disorder|substance use disorder"] who presents for initial evaluation per court assigned [text name="programname" default=""][text name="refSrc" default=""].
[comment memo="Presenting problems: demographics, list of current problems, diagnoses, prominent symptoms, prominent aspects of mental state exam, known specific biopsychosocial risks including incidents of self harm, suicidal ideation, and suicide attempts"]
[textarea name="presProb" default=""]. [var name="cxName"] is currently assigned to Human Service Worker [text name="HSWName" default=""]

[var name="cxName"]’s current reported diagnosis is [text name="currDx" default=""]
Client is currently experiencing [textarea name="currSymp" default=""] symptoms.
Client is currently prescribed [textarea name="currRx" default=""]

[checkbox name="currMHSA" value="Client denies any current mental health diagnosis|Client denies experiencing any symptoms at this time|Client denies prescription of any medications"]

MENTAL STATUS EXAM:
General:[checkbox name="variable_11" value="alert and oriented in all spheres|obtunded|disoriented"]
Behavior - general:[checkbox name="variable_13" value="in no acute distress|in acute psychological distress"]
Behavior - stability:[checkbox name="variable_14" value="calm|agitated"]
Behavior - interactivity:[checkbox name="variable_15" value="warm with comments and behavior|interactive|withdrawn"]
Behavior - eye contact:[checkbox name="variable_15" value="eye contact good|eye contact fair|eye contact avoidant"]
Mood/Affect - stated:[checkbox name="variable_16" value="normal|upbeat|euthymic|depressed"]
Mood/Affect - emotional range:[checkbox name="variable_17" value="normal|broad|restricted"]
Mood/Affect - intensity:[checkbox name="variable_18" value="normal|expansive|blunted|flat"]
Mood/Affect - congruence:[checkbox name="variable_19" value="mood is congruent with affect|mood and affect are not congruent"]
Thought form and content:[checkbox name="variable_20" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention:[checkbox name="variable_21" value="no difficulty with attention or concentration|had some attentional and concentration problems session"]
Perception - insight:[checkbox name="variable_22" value="normal insight|poor insight"]
Perception - general:[checkbox name="variable_23" value=normal|denied any preoccupations, obsessions, delusions, hallucinations or perceptual disturbances"]
Cognition/Memory:[checkbox name="variable_24" value="normal|grossly intact|below average|above average"]
Cognition/Memory - abstraction:[checkbox name="variable_25" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment:[checkbox name="variable_26" value="normal|good|poor|"]
Suicide/Assault:[checkbox name="variable_27" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"]

Recent circumstances that have lead to client involvement are [comment memo="triggering or provoking events and circumstances how and why these factors have affected the presentation of the client"]
[checkbox name="trgEvents" value="mental illness|substance use|physical illness|medication adherence|housingproblems|employment problems|financial problems|problems with primary supports|problems with non-primary supports|non-access to healthcare|cultural concerns|unsecure basic needs|maladaptive coping mechanisms|losses|Criminal Charges"]
[comment memo="other triggering events, response to events – feeling defeated/humiliated/provoked etc"]
[textarea name="precipitating" default=""]

Contributing lifetime experiences have been [comment memo="describe how and why the client’s lifetime experiences have contributed to the development of the current problems including: developmental factors, family history and relationships, psyhological and functional issues, social problems,substance use,history of illness and repsone to treatment and interventions"]
[textarea name="predisposing" default=""]

Some of the factors that keep these issues going are [comment memo="potential contributors that maintain the problem or may worsen the problem if not addressed such as insight, personality style, vulnerabilities, co-occurring conditions, employment status, lack of social supports, peer group, family attitudes, beliefs about behaviors"]
[textarea name="perpetuating" default=""]

[var name="cxName"]’s strengths/protective factors are [textarea name="protective" default=""]

[var name="cxName"]’s goals are  [comment memo="how the client understands the current situation and presentation, what do they want now and what are their goals they want to work towards"]
[textarea name="cxGoals" default=""]

Given the above, the current treatment plan includes [comment memo="area of focus for care and planning and possible interventions"]
[textarea name="txPlan" default=""]


The first individual counseling or gruop session is scheduled for [text name="indDate" default=""] at [text name="indTime" default=""] [checkbox name="indAmPm" value="AM|PM"]

A psychiatric evaluation is [select name="PsychEval" value="Not reccomended at this time|Reccomended|Completed"] [conditional field="PsychEval" condition="(PsychEval).is('Reccomended')"] based off assessment scheduled for [text name="psyDate" default=""] at [text name="psyTime" default=""][checkbox name="psyAmPm" value="AM|PM"]
[/conditional]