"Mental Health Assessment Form - Behavioral Healthcare"

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Mental Health Assessment Form
Client Name:
Date of Birth:
Medicaid Number:
Address:
City, State, Zip
Parent/Guardian (if applicable):
Phone Number:
Date of Service:
Time of Service:
Duration of Service:
Presenting Concern/Chief Complaint (include symptoms, intensity and duration):
Cultural Assessment/Strengths:
Mental Health Assessment Form
Client Name:
Date of Birth:
Medicaid Number:
Address:
City, State, Zip
Parent/Guardian (if applicable):
Phone Number:
Date of Service:
Time of Service:
Duration of Service:
Presenting Concern/Chief Complaint (include symptoms, intensity and duration):
Cultural Assessment/Strengths:
Mental Health Assessment Form
Client Name: _____________________________________
Mini Mental Status Exam:
Presentation (include
appearance, psychomotor
activity,
manner/attitude):
Speech (include
quality/quantity):
Emotions (include mood,
affect, impulse control):
Thought Process (include
productivity, continuity,
orientation, memory,
attention /concentration,
judgment, insight):
Thought Content (include
preoccupations,
perceptions, delusions):
Somatic (include sleep,
appetite, weight, energy):
Mental Health Assessment Form
Client Name: _____________________________________
Alcohol/Drug Assessment
Tobacco Use (current and
historical to include
amount and frequency,
age first used, current
frequency of use,
frequency in past 6
months, method of use):
Alcohol Use (current and
historical to include
amount and frequency,
age first used, current
frequency of use,
frequency in past 6
months, method of use):
Other Drug Use (current
Primary:
and historical to include
amount and frequency,
age first used, current
frequency of use,
frequency in past 6
months, method of use):
Secondary:
Tertiary:
Previous/Current Abuse
Treatments:
Mental Health Assessment Form
Client Name: _____________________________________
Prior Treatment History (including
high levels of treatment, such as residential, day
:
treatment)
Current Medications (type, frequency, dosage):
Mental Health Assessment Form
Client Name: _____________________________________
Risk Assessment:
History of violence toward
self or others:
History of hospitalizations:
Medical Concerns:
Cause of dangerousness:
Suicidal Ideation
Homicidal Ideation
Grave Disability
If Suicidal Ideation:
Suicidal behavior:
Ideation: yes/no
Plan: yes/no
Intent: yes/no
Precipitants/stressors/interpersonal triggers:
Change in current treatment
Access to weapons
Protective Factors:
Internal (ability to cope,
External (responsibility to
frustration tolerance):
children/pets, social supports):
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