Form LIC625 Appraisal / Needs and Services Plan - California

Form LIC 625 Instructions

To assess the client's mental state and needs, Form LIC 625 is divided into seven sections:

1. Introductory Information . This includes the client's name, date of birth, sex, and information about the facility where the client may be admitted or is currently a patient.
2. Background Information . A description of the person's medical and psychiatric history. Any physical or mental limitations, and the ability of the client to perform simple household chores or handle money.
3. Socialization. An assessment of the patient's ability to maintain personal relationships.
4. Emotional. How does the person respond to events emotionally? Are they incapable of maintaining control over their emotional responses?
5. Mental. The level of the patient's intellectual functioning, and difficulty making decisions in daily life.
6. Physical/Health. A description of any physical development problems or inability to maintain basic health habits.
7. Functioning Skills. A description of the patient's ability to or lack of development in independent functioning skills.