"Initial Psychiatric Assessment Form - Contra Costa Health Services"

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NAME/MRN:
B
H
D
EHAVIORAL
EALTH
IVISION
INITIAL PSYCHIATRIC ASSESSMENT
DATE OF SERVICE _________________________
RU# ___________________
STAFF #
_____________________________
HOURS _______________________ MINUTES ________________
Code Activity:
361 EVAL/RX
Location:
1 Office
2 Field
4 Home
5 School Satellite
18 Other
Service Strategies: (Please check up to three, if applicable)
50 Peer/Fam Deliv Svcs
53 Supportive Education
56 Ptnrshp:Soc Svcs
59 Integrated Svcs:MH-Dvlp Disbled
51 Psych Education
54 Prtnrshp:LawEnfcmt
57 Ptnrshp:Subs Abuse
60 Ethnic-Specific Service Strategy
52 Family Support
55 Ptnrshp:Health Care
58 IntSvcs:MH/Aging
61 Age-Spec Svc Strategy
99 Unknown
Assessment in language other than English:
Spanish
Other ____________________________________
Interpreter
Name of Interpreter: _________________________________
Identifying Information:
Legal Name: ____________________________________________
DOB/Age:______________________
Preferred Name: _________________________________________
Gender:
Male
Female
Transgender F-M
Transgender M-F
Intersex
Other _____
Single
Married
Significant Other
Separated
Divorced
Marital Status:
Address: _________________________________________________
Phone #: ________________________
Emergency Contact / Significant Other: ________________________________________
_________________
Name
Phone
Primary concerns per consumer: _______________________________________________________________
____________________________________________________________________________________________
Presenting Problem/ Recent Course of Illness: ____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Consumer and Family Strengths (Positive factors to facilitate treatment e.g. faith, resilience, etc.):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
1
MHC113Initial Psychiatric Assessment (9/13)
NAME/MRN:
B
H
D
EHAVIORAL
EALTH
IVISION
INITIAL PSYCHIATRIC ASSESSMENT
DATE OF SERVICE _________________________
RU# ___________________
STAFF #
_____________________________
HOURS _______________________ MINUTES ________________
Code Activity:
361 EVAL/RX
Location:
1 Office
2 Field
4 Home
5 School Satellite
18 Other
Service Strategies: (Please check up to three, if applicable)
50 Peer/Fam Deliv Svcs
53 Supportive Education
56 Ptnrshp:Soc Svcs
59 Integrated Svcs:MH-Dvlp Disbled
51 Psych Education
54 Prtnrshp:LawEnfcmt
57 Ptnrshp:Subs Abuse
60 Ethnic-Specific Service Strategy
52 Family Support
55 Ptnrshp:Health Care
58 IntSvcs:MH/Aging
61 Age-Spec Svc Strategy
99 Unknown
Assessment in language other than English:
Spanish
Other ____________________________________
Interpreter
Name of Interpreter: _________________________________
Identifying Information:
Legal Name: ____________________________________________
DOB/Age:______________________
Preferred Name: _________________________________________
Gender:
Male
Female
Transgender F-M
Transgender M-F
Intersex
Other _____
Single
Married
Significant Other
Separated
Divorced
Marital Status:
Address: _________________________________________________
Phone #: ________________________
Emergency Contact / Significant Other: ________________________________________
_________________
Name
Phone
Primary concerns per consumer: _______________________________________________________________
____________________________________________________________________________________________
Presenting Problem/ Recent Course of Illness: ____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Consumer and Family Strengths (Positive factors to facilitate treatment e.g. faith, resilience, etc.):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
1
MHC113Initial Psychiatric Assessment (9/13)
NAME/MRN
Psychiatric History (include hospitalizations and dates, suicide attempts, history of intervention):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Psychiatric Medication History (Current and Past, side effects, adherences & outcomes)
Current:
None Past:
None
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Alcohol/ Drug Use History: (Check all appropriate and provide details.)
Unknown
No Current Substance Abuse
No Past Substance Abuse
Currently Clean & Sober for:
>3 Mos.
>1 Yr
Past
Present
Past
Present
Past
Present
Alcohol
Nicotine
Caffeine
Cocaine
Past
Present
Marijuana
Past
Present
Amphetamines
Past
Present
Past
Present
Past
Present
Past
Present
Opiates
Ecstasy
Hallucinogens
Past
Present
Past
Present
Past
Present
Sedatives
Inhalants
Energy Drinks
Past
Present
Other:
Specify: ______________________________________________________
____________________________________________________________________________________________
Medical History (include illnesses, surgeries, CNS, head injuries):
Date of Last Physical: _______________
Physician(s)/clinic: _________________ Phone #: _______________
Weight: _____________ Height: _____________ BMI: _____________
Allergies (Meds & Other) / Adverse Reaction: ______________________________________________________
Active Medical Concerns, History of Hospitalizations/Surgeries: ________________________________________
Non-Psych Med/OTC __________________________________________________________________________
Review of Systems:
No Significant issues revealed
CV
Renal
GI
Hepatic
CNS
GU
Metabolic
CA
PULM
Gyn
ID/HIV
Sexually Active
Contraceptive Method _______________
Risk of Pregnancy
Pregnant
Breast-Feeding
LMP: _____________
Pregnancy and Birth History (<18):__________________________________________________________________________
Developmental History (<18): ______________________________________________________________________________
MHC113Initial Psychiatric Assessment (9/13)
2
NAME/MRN
Family Psychiatric History:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Psychosocial History (e.g. education, family, vocational, military, legal):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Psychosocial Risk Factors: (Check all that apply.) Document details.
Victim of Physical Abuse
History of Self-injurious Behavior
Victim of Sexual Abuse
History of Suicidal Behavior
Trauma or Loss in the Family
Family History of Suicide
Domestic Violence:
Victim
Perpetrator
Access to Firearms (family, friends, self)
History of Substance Abuse
Access to Other Means of Suicide
History of Assaultive Behavior
Lack of Social Support
History of Threatening Behavior
History of Foster Care
History of Inappropriate Sexual Behavior
Homelessness
Behavior Influences by Delusions or Hallucinations
Other
Comments:
MENTAL STATUS EXAMINATION
APPEARANCE/GROOMING
Unremarkable
Remarkable for:
PSYCHO-MOTOR ACTIVITY
Unremarkable
Remarkable for:
ATTITUDE/RELATEDNESS
Unremarkable
Remarkable for:
SPEECH
Unremarkable
Remarkable for:
MOOD
Unremarkable
Remarkable for:
AFFECT
Unremarkable
Remarkable for:
THOUGHT PROCESS
Unremarkable
Remarkable for:
THOUGHT CONTENT
Unremarkable
Remarkable for:
PERCEPTUAL DISTURBANCE
Unremarkable
Remarkable for:
ORIENTATION
Unremarkable
Remarkable for:
MEMORY/CONCENTRATION
Unremarkable
Remarkable for:
FUND OF KNOWLEDGE
Unremarkable
Remarkable for:
INTELLECT/ABSTRACT THINKING
Unremarkable
Remarkable for:
INSIGHT/ JUDGEMENT
Unremarkable
Remarkable for:
IMPULSE CONTROL
Unremarkable
Remarkable for:
Additional Observations: ________________________________________________________________________________
MHC113Initial Psychiatric Assessment (9/13)
3
NAME/MRN
Current Risk Assessment:
Danger to SELF (Intent, Plan Means): _______________________________________________________________________
Danger to OTHER (Intent, Plan Means): _____________________________________________________________________
Grave Disability: ________________________________________________________________________________________
Clinical Summary (Optional):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Diagnostic Impression: DSM Code and Narrative – Designate diagnosis which is primary focus of treatment with a “P”
_________
_________
Axis I
p / s
_________
_________
Axis I
p / s
_________
_________
Axis I
Axis II
_________
_________
V71.09
799.9
p / s
_________________________________ Check If None
Axis III
CONTRIBUTING STRESSORS – Problems related to:
Axis IV
A – Primary Support
B – Social Environment
C – Education
D – Occupation
E – Housing
F – Economic
G – Access to Health Care
H – Legal System
I – Other/ System/ War
Axis V
CURRENT GAF: __________
HIGHEST GAF PAST YEAR: __________
FUNCTIONAL IMPAIRMENT: (IF MODERATE OR ABOVE, MAY WARRANTS TARGETED CASE MANAGEMENT)
None
Mild
Mod
Severe
None
Mild
Mod
Severe
Family Relations
Peer Relations
Physical Health
Academic/Vocational Performance
Self Care
Substance Abuse
TARGETED SYMPTOMS:
None
Mild
Mod
Severe
None
Mild
Mod
Severe
Cognition/Memory/Thought
Perceptual Disturbance
Attention/Impulsivity
Antisocial Behavior
Socialization/Communication
Destructive/Assaultive
Depressive Symptoms
Mania/Agitation/Lability
Anxiety/Phobia/Panic Attack
Somatic Disturbance
Affect Regulation
Other_______________
MHC113Initial Psychiatric Assessment (9/13)
4
NAME/MRN
Initial Treatment Plan/Targeted Case Management:
Does consumer meet the criteria for TCM? (May include moderate or above Functional Impairment and/or risk of losing
placement/housing, need for financial support, social support, prevocational/employment assistance, rehabilitation, AOD services, or
other programs or services considered necessary.)
No
Yes
Explain: _________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Referral to Coordination of Care with:
PCP
Case Management
Therapist
Family/ Other Support
Substance Abuse Tx
Housing
Community Agencies
Vocational Rehab
Social Security
Details: _______________________________________________________________________________________
Labs Ordered: __________________________________________________________________________________
______________________________________________________________________________________________
Medications Prescribed / Dosage / Frequency:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Drug Information Sheet for each medication was given to consumer and family.
Benefits/Risks/Possible adverse effects of medication and Alternatives to medication have been discussed.
An opportunity was given to ask questions.
The consumer and/or family appear to understand the information on the form.
If appropriate, discuss the interaction of psychiatric medication with the following: Pregnancy, Lactation,
Alcohol, Nutrition, and Non-Psychiatric Medications
An Informed Consent was signed within the past two years.
Consumer (Family) is able to manage own medication:
Yes
No
If not, explain:
_______________________________________________________________________________
Additional Information:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
MD/DO/NP Signature:
Date:
PRINT FULL NAME AND TITLE ____________________________________________________________________
Data Entry Clerk Initials
MHC113Initial Psychiatric Assessment (9/13)
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