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Behavior - interactivity:[checkbox name="variable_15" value="warm with comments and behavior|interactive|withdrawn"]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]
SUMMARY

cxName is a year old , with a history of who presents for initial evaluation per court assigned .
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
. cxName is currently assigned to Human Service Worker

cxName’s current reported diagnosis is
Client is currently experiencing
symptoms.
Client is currently prescribed




MENTAL STATUS EXAM:
General:
Behavior - general:
Behavior - stability:
Behavior - interactivity:
Behavior - eye contact:
Mood/Affect - stated:
Mood/Affect - emotional range:
Mood/Affect - intensity:
Mood/Affect - congruence:
Thought form and content:
Attention:
Perception - insight:
Perception - general:
Cognition/Memory:
Cognition/Memory - abstraction:
Judgment:
Suicide/Assault:

Recent circumstances that have lead to client involvement are triggering or provoking events and circumstances how and why these factors have affected the presentation of the client

other triggering events, response to events – feeling defeated/humiliated/provoked etc


Contributing lifetime experiences have been 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


Some of the factors that keep these issues going are 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


cxName’s strengths/protective factors are


cxName’s goals are how the client understands the current situation and presentation, what do they want now and what are their goals they want to work towards


Given the above, the current treatment plan includes area of focus for care and planning and possible interventions



The first individual counseling or gruop session is scheduled for at

A psychiatric evaluation is

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.59, 59 form elements, 147 boilerplate words, 10 text boxes, 9 text areas, 22 checkboxes, 5 drop downs, 5 variables, 7 comments, 1 conditionals, 106 total clicks
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