DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

COMMUNITY MENTAL HEALTH REHABILITATION SERVICES

Intensive In-Home and Therapeutic Day Treatment Services

At-Risk Of Physical Injury Screening

Name:Date:

Mental Status Examination

Consciousness: AlertDrowsyDeliriousStuporous

Appearance:Well-groomedDisheveledThinOverweight

Attitude:CooperativeUncooperativeFriendlyHostile

Behavior:AppropriatePsychomotor Agitation Psychomotor Retardation

Speech:Non-verbal

Verbal:FluentNon-fluentCoherentIncoherent Pressured limited

Mood:EuthymicDepressedAnxiousManic

Affect:FullRestrictedFlat Appropriate Inappropriate

Thought Process:Logical/LinearDisorganized Loosening of Associations

Flight of Ideas Circumstantial Tangential

Unable to Assess

Thought Content:Auditory HallucinationsVisual Hallucinations

Other HallucinationsDelusional

Unable to Assess

Yes / No
1. Within the past 30 days has the individual had any suicidal thoughts?
Yes / No
2. Within the past 30 days has the individual had a plan to harm themselves or someone else?
Yes / No
3. Within the past 30 days has the individual attempted suicide?
Yes / No
4. Within the past 30 days has the individual experienced command hallucinations to harm self or others or engaged in reckless behavior?

If “yes,” to reckless behavior state the behavior:______

5. Within the past 30 days has the individual engaged in self-mutilation/cutting or other self-injurious behaviors? / Yes / No
Yes / No
6. Within the past 30 days has the individual engaged in reckless behavior, i.e. fire setting, use of weapons, criminal activity, etc.?

If “yes,” state behavior:______

Yes / No
7. Within the past 30 days has the individual run away from home?
Yes / No
8. Within the past 30 days has the individual exhibited any other behaviors that determine the individual is at risk of physical injury?

If “yes,” state behavior:______

Yes / No
9. Within the past 30 days has the individual displayed an escalation in behavior that may result in the individual being removed from the home without intensive interventions being put in place?

If “yes,” state behavior:______

The person completing this risk screening must be a LMHP, LMHP-S, LMHP-R or

LMHP-RP

Screener Name(printed)
Screener Credentials
Screener Employer
Signature
Date of Screening

DMAS-P502