CONFIDENTIAL
PlacerCounty Systems of CareCHILD/YOUTHBIOPSYCHOSOCIAL ASSESSMENT
This form is to be used for all Biopsychosocial Assessments for children/youth aged 0-17.
Case Number: New Assessment
Staff Member: Re-Assessment
Division/Office: Addendum (Other)
Child’s Name: / SSN:
Date of Birth: / Gender F M / Date of Assessment:
Interpreter Used During Assessment? / Y N / Name of Interpreter:
Reason for Referral/Presenting Problem (in client’s own words, when possible):
CLINICAL ASSESSMENT
SIGNIFICANT PAST HISTORY
Lifespan / Developmental History:A.Pre-natal/perinatal factors and health at birth:
B.Developmental milestones:
C.Educational history and/or pre-referral services:
D.Mental health services received during lifetime:
E.Other lifespan/developmental/cultural issues:
F.Family of origin history (psychiatric, relational and environmental issues):
CARETAKER INFORMATION
A.Birth family constellation:
B.Caretaker family constellation:
C.Impact of child’s emotional/behavioral issues on family:
D.Interventions attempted by family/caretaker and outcomes:
E.Interest and availability of family/caretakers to participate in intensive services:
PROBLEM AREAS/ASSESSMENT:
Key: / Severity Rating: / 1 = Mild / 2 = Moderate / 3 = Severe / N/A = Not ApplicableDuration Rating: / 1 = < 1 Month / 2 = 1 - 6 Months / 3 = 7 - 11 Months / 4 = > 1 Year
Problem Area / History / Severity / Duration
1. Self Harm / Yes No / 123N/A / 1234
2. Suicidal Behavior / Yes No / 123N/A / 1234
3. Violence / Yes No / 123N/A / 1234
4. Run Away / Yes No / 123N/A / 1234
5. Physical Abuse / Yes No / 123N/A / 1234
6. Early Child Neglect / Yes No / 123N/A / 1234
7. Sexual Abuse / Yes No / 123N/A / 1234
8. Domestic Violence / Yes No / 123N/A / 1234
9. Substance Abuse / Yes No / 123N/A / 1234
If Yes, explain (include past & present use of tobacco/alcohol/caffeine/illicit drugs):
10. Legal Trouble / Yes No / 123N/A / 1234
11. Addictive Behavior / Yes No / 123N/A / 1234
12. Eating Disorder / Yes No / 123N/A / 1234
13. Fire Setting / Yes No / 123N/A / 1234
14. Academic Problems / Yes No / 123N/A / 1234
15. Sexual Perpetration / Yes No / 123N/A / 1234
16. Sexual Acting Out / Yes No / 123N/A / 1234
17. Destruction of Property / Yes No / 123N/A / 1234
18. Gang Activity / Yes No / 123N/A / 1234
19. Cruelty To Animals / Yes No / 123N/A / 1234
20. Compulsive Behavior / Yes No / 123N/A / 1234
21. Family Relational Problem / Yes No / 123N/A / 1234
22. Hospitalization / Yes No / 123N/A / 1234
Brief narrative of problem areas identified above:
CURRENT FUNCTIONING:
Current Symptoms/Problems: (rate severity and duration for each)
Duration Rating: / 1 = < 1 Month / 2 = 1 - 6 Months / 3 = 7 - 11 Months / 4 = > 1 Year
Severity / Duration / Severity / Duration
1. Anxiety / 123N/A / 1234 / 15. Unusual Ideation / 123N/A / 1234
2. Panic Attacks / 123N/A / 1234 / 16. Unusual Behavior / 123N/A / 1234
3. Phobia / 123N/A / 1234 / 17. Paranoid Ideation / 123N/A / 1234
4. Obsessive/Compulsive / 123N/A / 1234 / 18. Gender Identity Issues / 123N/A / 1234
5. Somatization / 123N/A / 1234 / 19. Eating Disorders / 123N/A / 1234
6. Depression / 123N/A / 1234 / 20. Poor Judgment / 123N/A / 1234
7. Impaired Memory / 123N/A / 1234 / 21. Lack of Support System / 123N/A / 1234
8. Poor Self Care Skills / 123N/A / 1234 / 22. Poor Interpersonal Skills / 123N/A / 1234
9. Loss of Interest / 123N/A / 1234 / 23. Conduct Problems / 123N/A / 1234
10. Loss of Energy / 123N/A / 1234 / 24. School Problems / 123N/A / 1234
11. Hallucinations/Delusions / 123N/A / 1234 / 25. Family Problems / 123N/A / 1234
12. Sleep Disturbance / 123N/A / 1234 / 26. Independ. Liv'g Problems / 123N/A / 1234
13. Appetite Disturbance / 123N/A / 1234 / 27. Tics/Unusual Body Mvmts / 123N/A / 1234
14. Weight Change / 123N/A / 1234 / 28. Other: / 123N/A / 1234
Explanation of all factors identified above:
Client/parent reports no outstanding medical problemsClient/parent reports no known allergies
Client/parent reports the following medical conditions:
Primary Care Physician’s name and phone #:
Date of last physical examination:
List alternative treatments/therapies (i.e., biofeedback, acupuncture, hypnosis, etc.):
None known/reported
MEDICAL HISTORY: (document significant past and present medical conditions, including allergies)
MEDICATION HISTORY: (ATTACH RELEASES)
A. Current psychiatric medications: None reported by client
Drug Name
/ Dose/Frequency / Benefit/
Side Effects / Prescribed By:
(Dr.'s Name) / When Prescribed? / When is Next Refill Required?
B. Past psychiatric medications: None reported by client
Drug Name
/ Dose/Frequency / Benefit/
Side Effects / Prescribed By:
(Dr.'s Name) / When Prescribed? / When is Next Refill Required?
C. Other medications: None reported by client
(Include non-psychiatric prescriptions and alternative medications, i.e. homeopathic, herbal remedies)
Drug Name
/ Dose/Frequency / Benefit/
Side Effects / Prescribed By:
(Dr.'s Name) / When Prescribed? / When is Next Refill Required?
D. Medication allergies or adverse reactions: None reported by client
Drug Name
/ ReactionE. Does client follow medication regime? Yes No Explain:
Client Strengths and Interests:
Client’s Current and Significant Past Social Supports, Family Supports, Significant Relationships, Religious and Spiritual Supports/Affiliations:
Other Agencies / Systems Client is Involved With or is Receiving Services From:
CLIENT'S LEGAL HISTORY:
Informal Probation / Formal Probation / Child Welfare Services / None ReportedMENTAL STATUS EXAM:
Description / DescriptionAppearance / clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age,clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age,clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age,
clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age,clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age,clean,disheveled,dirty,odiferous,bizarre,meticulous,posturing,older than stated age,younger than stated age, / Thought Form / logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,
logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,logical,linear,tangential,loose,circumstantial,scattered,blocking,fragmented,flight of ideas,ruminative,perseverative,
Attitude / cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic,cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic,cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic,
cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic,cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic,cooperative,uncooperative,angry,hostile,guarded,provocative,sarcastic,irritible,apathetic, / Thought Content / within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,
within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,within normal limits,delusions-grandiose,delusions-paranoid,delusions-somatic,delusions-jealous,delusions-erotomanicdelusions-thought brodcastinghypervigilance,obsessions,compulsions,
Behavior / sleeping-adequate,sleeping-fair,sleeping-poor,eating-adequate,eating-fair,eating-poor,energy level-adequate,energy level-fair,energy level-poor,sleeping-adequate,sleeping-fair,sleeping-poor,eating-adequate,eating-fair,eating-poor,energy level-adequate,energy level-fair,energy level-poor,sleeping-adequate,sleeping-fair,sleeping-poor,eating-adequate,eating-fair,eating-poor,energy level-adequate,energy level-fair,energy level-poor, / Speech / clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,
clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,clear,coherent,incoherent,halting,mute,loud,soft,rapid,pressured,slurred,stammer,monotone,monosyllabic,rambling,echolalia,word salad,clanging,
Motor Activity / calm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-nonecalm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-nonecalm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-none
calm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-nonecalm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-nonecalm,restless,pacing,withdrawn,panicky,tics,tremors,hyperactive,fidgety,repetitive motor activity,eye contact-direct,eye contact-staring,eye contact-evasiveeye contact-none / Memory / immediate-adequate,immediate-fair,immediate-poor,recent-adequate,recent-fair,recent-poor,remote-adequate,remote-fair,remote-poor,immediate-adequate,immediate-fair,immediate-poor,recent-adequate,recent-fair,recent-poor,remote-adequate,remote-fair,remote-poor,immediate-adequate,immediate-fair,immediate-poor,recent-adequate,recent-fair,recent-poor,remote-adequate,remote-fair,remote-poor,
Sensorium / alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4,alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4,alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4,
alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4,alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4,alert,lethargic,disoriented,confused,intelligence level-average,intelligence level-above average,intelligence level-below average,oriented to-person,oriented to-place,oriented to-day/time/year,oriented to-situation,oriented x 4, / Concentration / attentive,distracted,unable to concentrate,serial 7's,attentive,distracted,unable to concentrate,serial 7's,attentive,distracted,unable to concentrate,serial 7's,
Mood / euthymic,dysphoric,elevated,expansive,euphoric,labile,euthymic,dysphoric,elevated,expansive,euphoric,labile,euthymic,dysphoric,elevated,expansive,euphoric,labile,
euthymic,dysphoric,elevated,expansive,euphoric,labile,euthymic,dysphoric,elevated,expansive,euphoric,labile,euthymic,dysphoric,elevated,expansive,euphoric,labile, / Judgment / adequate,fair,poor,
Affect / within normal limits,restricted,blunted,flat,within normal limits,restricted,blunted,flat,within normal limits,restricted,blunted,flat, / Insight / self-aware,blames others or external factors,denies illness/disability,self-aware,blames others or external factors,denies illness/disability,self-aware,blames others or external factors,denies illness/disability,
Perception / within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,
within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,
within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization,within normal limits,haalcinations-visual,hallucinations-auditory,haalucinations-olfactory,hallucinations-tactile,hallucinations-gustatory,illusions,deja-vudepersonalization,derealization, / Abstract Thinking / adequatefairpoorconcrete,adequatefairpoorconcrete,adequatefairpoorconcrete,
Additional information:
ASSESSMENT OF RISK:
CurrentRisk Factors: (check all that apply)
● / Suicidality / None / Ideation / Plan / Intent w/o means / Intent w/ means / N/A● / Homicidality / None / Ideation / Plan / Intent w/o means / Intent w/ means / N/A
● / If risk exists, client is able to contract not to harm: / Self / Others / N/A
● / Impulse control: / Sufficient / Moderate / Minimal / Inconsistent / Explosive / Unknown
● / Substance abuse: / None / Abuse / Dependence / Unstable Remission / Unknown
● / Medical risks: / No / Yes If “Yes”, explain: / Unknown
Brief Narrative Explanation of Risk History: (Significant history of suicidal, homicidal, impulse control, medical or substance abuse behavior that may affect client's current level of risk or impairment to functioning. Include description of plan / ideation / intent checked above).
FORMULATION:(Identify problem areas and underlying dynamics. Include information used to make differential diagnosis.)
RECOMMENDED SERVICES: (Check all that apply.)
Community referrals made, no further services needed.
Medication assessment By Primary Care Physician By CSOC Psychiatrist
Individual therapy, frequency recommended is times per month for 3 months 6 months
Family therapy
Collateral, describe reason:
Group, specify type:
Testing, specify type: (i.e., Conner's, Beck, etc.)
Other, specify:
Assessment completed by:
Therapist/Clinician/Practitioner Signature:(include licensure, degree, or job title): / Date:
Type Name: / Work Unit/
Organization: / Phone #
Placer CountyUse Only
Supervisor's Signature: ______Date: ______
PlacerCounty Systems of Care
Client Name: / Case Number:Type of Diagnosis: Admission Discharge Update
Axis I: Clinical Disorders; Other Conditions That May Be a Focus of Clinical Attention (ICD-9-CM)
. / a.. / b.
. / c.
. / d.
Substance Abuse/Dependency:
Does a substance abuse/dependency issue exist? / Yes No Unknown/Not ReportedIf yes, which substance disorder is the primary substance abuse diagnosis? / a b c d
Axis II: Personality Disorders; Mental Retardation (ICD-9-CM)
. / e.. / f.
Covered Axis I or Axis II Diagnosis:
Which Axis I or Axis II Diagnosis is the Medi-Cal covered ICD-9 Diagnosis? a b c d e fAxis III General Medical Condition: Summary by Client Report or Medical Record Documentation
Allergies / Carpal Tunnel / Epilepsy/Seizures / Migraines / Physical DisabilityAnemia / Chronic Pain / Heart Disease / Multiple Sclerosis / Psoriasis
Arterial Sclerotic Disease / Cirrhosis / Hepatitis / Muscular Dystrophy / STDs
Arthritis / Cystic Fibrosis / Hypercholestoralemia / No General Medical Condition / Stroke
Asthma / Deaf/Hearing Impaired / Hyperlipidemia / Obesity / Tinnitus
Birth Defects / Diabetes / Hypertension / Osteoporosis / Ulcers
Blind/Visually Impaired / Digestive Disorders / Hyperthyroid / Other / Unknown/
Not Reported
Cancer / Ear Infections / Infertility / Parkinson’s Disease
Axis IV: Psychosocial and Environmental Problems (DSM-IV TR). Check yes or no for each problem.
Primary Support Group / Yes No / Occupational / Yes No / Access to Health Care / Yes NoSocial Environment / Yes No / Housing / Yes No / Legal System/Crime / Yes No
Educational / Yes No / Economic / Yes No / Other Problems / Yes No
Trauma:
Has the client witnessed violence, lived through a natural disaster, been a combatant or civilian in a war zone, witnessed or been a victim of a severe accident, or been the victim of physical, emotional, or sexual abuse? /Yes
No
UnknownAxis V: Global Assessment of Functioning Scale (GAF – DSM-IV TR)
Current: / Highest in last 12 months: / Lowest in last 12 months:Transcribed by:
/Date:
Print Name of Diagnosing Practitioner:
/Date:
(Must be Master’s level or above)
Signature of Licensed Practitioner:
/Date:
(Must include licensure after signature)
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CARE141 e Rev. 8-20-13