Mental Health Plan / Coordinator:
Program: / Phone:
Cost Center-Reporting Unit: / CHILD & YOUTH COMPREHENSIVE
ASSESSMENT / Fax:
Program Admit Date: / Date Completed: / Minutes:
Requested AUTHORIZATION / START DATE: / END DATE:
CLIENT NAME: / Sex:
M F / DOB: / Age Today: / Client MRN:
SSN:
CAREGIVER: / Phone: / Relationship:
Address: / City: / Zip:
LEGAL GUARDIAN: / Phone: / Relationship:
Address: / City: / Zip:
REFERRAL SOURCE: / CWS/CPS School Physician Parent / Caregiver
Therapist Probation Self Other / Phone: / Contact:
LEGAL STATUS AND SPECIAL POPULATIONS:
Voluntary Dep. of Court (300 W&I) Alta Regional Ctr. 26.5 / AB3632Foster Child On Probation (600 W&I) Aid to Adoptive Parent(s) Other / Comments:
Language spoken most frequently in the home (check only one):
1 - Cambodian / 4 - Hmong / 7 - Lao / 10 - Romanian / 13 - Spanish / 16 - Tongan
2 - Cantonese / 5 - Japanese / 8 - Mandarin / 11 - Russian / 14 - Tagalog / 17 - Vietnamese
3 - English / 6 - Korean / 9 - Mien / 12 - Samoan / 15 - Thai / 18 -
FUNCTIONAL IMPAIRMENT PRESENTING PROBLEMS / TARGETED SYMPTOMS / REASONS FOR SERVICE:
Functioning (Please assess how current symptoms have effected the level of impairment in the following categories and indicate anticipated impairment at discharge)
Impairment Level (Circle One for Each identified Category) / Anticipated Impairment at DischargeCategories / None / Mild / Moderate / Marked / Extreme / (E.g., “2”)
Problems w/primary Support / 1 / 2 / 3 / 4 / 5
School Performance due to Mental Health Issues
(Note Level and check if other categories are applicable) / 1 / 2 / 3 / 4 / 5
□ Truant □ School suspension □ AB3632
Friendship/Peer Relationships / 1 / 2 / 3 / 4 / 5
Self care/daily activities / 1 / 2 / 3 / 4 / 5
Depressive Symptoms / 1 / 2 / 3 / 4 / 5
Mania/Agitation/Lability Symptoms / 1 / 2 / 3 / 4 / 5
Physical Health Status/Somatic Disturbances / 1 / 2 / 3 / 4 / 5
Oppositional to following directions / □ school / 1 / 2 / 3 / 4 / 5
□ home / 1 / 2 / 3 / 4 / 5
Appetite disorder/Sleeping Disturbances (circle) / 1 / 2 / 3 / 4 / 5
Anxiety/Phobia/Panic Attacks / 1 / 2 / 3 / 4 / 5
Interaction with legal system due to Mental Health Issues / 1 / 2 / 3 / 4 / 5
Ability to Concentrate/Attention/Cognition/Memory/Thought / 1 / 2 / 3 / 4 / 5
Ability to Control His/Her Temper/Affect Regulation/Impulsivity / 1 / 2 / 3 / 4 / 5
Destructive/Assaultive / 1 / 2 / 3 / 4 / 5
Problems related to socialization/Communication / 1 / 2 / 3 / 4 / 5
Perceptual Disturbances (Hallucination, Delusions, Paranoia…) / 1 / 2 / 3 / 4 / 5
Other: / 1 / 2 / 3 / 4 / 5
YLO Child Initial Assessment 12/17/07 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 7 of 7
CLIENT NAME: / CLIENT MRN#:PROBLEM AREA ASSESSMENT / FUNCTIONAL IMPAIRMENT:
Rate the following problem areas. Problems marked “Severe” must be followed up on immediately. Provide details in the PRESENTING PROBLEMS section and an action plan in the SUMMARY section on page 6.
PROBLEM AREAS:
/ History (past)Yes No / Severity of Problem in last 2 months (current)
None Insignificant Mild Moderate Severe / Potential Risk (immediate future, up to 60 days)
None Insignificant Mild Moderate Severe
1. Self-harm (e.g., cutting, head banging, high risk behavior)
2. Suicidal ideation/behavior
3. Violence (e.g., fighting, aggression, physical assault)
4. Homicidal ideation/behavior
5. Psychiatric hospitalization / crisis services
6. Loss of placement
7. Runaway
8. Physical abuse
9. Sexual abuse
10. Domestic violence / violent environment
11. Legal trouble
12. Drug or alcohol abuse
13. Addictive behaviors (e.g., eating, dieting, gambling, etc.)
14. Academic (or job) trouble
15. Perpetration of sexual assault or sexual acting out
16. Destruction of property or vandalism
17. Fire setting
18. Gang activity or association
19. Isolation, rejection by peers, compulsive or odd behavior / belief
20. Enuresis / encopresis
21. Cruelty to animals
22. Other problem area (specify):
PSYCHOSOCIAL HISTORY (Check below and circle how it applies to all that apply below, as appropriate)
Category / None/Unk
Family involvement in current problem / None / some support / moderate / Very supportive
Family Interpersonal relationships (including parents and siblings) / None / Explain:
Divorce/Remarriage/Blended Family / None / Explain:
Level of acculturation / None / mild / moderate / severe / Fully integrated
Family acculturation-Generational differences / None / mild / moderate / severe / Fully integrated
Language issues / None / Non-English / Limited English / Bilingual / Literacy Level limited
Immigrant/Refugee Experience / None / (<1 yrs) / (<2 yrs) / 1st Generation / 2nd Generation
Family Living situation and stability / None / Unstable / Stable / Explain:
Experiences of discrimination / None / once in awhile / Frequent
Chronic or Terminal Illness/Death of Caregiver / None / Who? / Explain:
Family History of Alcohol/Substance Abuse History / None / Who? / Explain:
Familial Criminal Justice Involvement / None / Who? / Explain:
Family History of Abuse / Physical / None / Who? / Explain:
Sexual / None / Who? / Explain:
Emotional / None / Who? / Explain:
Family Mental Health History / None / Explain:
Family Suicide/Suicide Attempt/ Unexplained Death / None / Who? / Explain:
YLO Child Initial Assessment 12/17/07 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 7 of 7
CLIENT NAME: / CLIENT ID#:CLIENT’S MENTAL HEALTH HISTORY: / INCLUDE:
· Earliest symptoms
· Age at onset
· Family understanding of the problem
· Other supports/stressors at the time of onset
· Response to treatment
· Other potential contributing factors
Yes No Previous outpatient mental health services? When/where? Transfer
Yes No Previous crisis contact? Number of crisis unit visits without hospitalization in past 6 months: 0 1 2 or more Most recent date:
Yes No Previous psychiatric hospitalization? Number of psychiatric hospitalizations in past 6 months: 0 1 2 or more Most recent date:
Number of days hospitalized in the past 6 months:
Yes No Use of traditional or alternative healing practices (describe, with results):
SUBSTANCE USE/ABUSE (Please answer the following questions about all current drug and alcohol use.) List applicable drug(s) for items marked “True”:
1. / True False Drinking or drug use sometimes causes me to miss school, work, or important appointments.
2. / True False I sometimes drink or use drugs when it is dangerous to do so.
3. / True False I sometimes have problems with the police or school authorities due to my drinking or drug use.
4. / True False I sometimes drink or use drugs even though they cause problems in my life.
5. / True False I need more to get drunk or high now than I used to. (Tolerance)
6. / True False Trying to quit makes me sick; I get withdrawal symptoms. (Withdrawal)
7. / True False I sometimes end up drinking or using more than I meant to.
8. / True False I have tried to quit before, but failed. (Give approximate dates for each applicable drug.)
9. / True False I spend more and more time getting and using drugs/alcohol.
10. / True False I sometimes choose drugs or alcohol over friends and family.
11. / True False I keep using even though the drug/alcohol makes me sick or messes with my mind.
TYPE OF SUBSTANCE
/PRENATAL EXPOSURE
/AGE AT FIRST USE
/CURRENT SUBSTANCE USE
/Check if ever used:
ALCOHOL / Unknown / None/ Denies / Current
Use / Current
Abuse / Current
Dependence / In Recovery / Client-perceived Problem?
Y N
AMPHETAMINES (Speed/Uppers, Crank, Ritalin) / Y N
COCAINE / CRACK / Y N
OPIATES (Heroin, Opium, Methadone) / Y N
HALLUCINOGENS (LSD, Mushrooms, Peyote, Ecstasy) / Y N
SLEEPING PILLS, PAIN KILLERS, VALIUM, OR SIMILAR / Y N
PCP (PHENCYCLIDINE) OR DESIGNER DRUGS (GHB) / Y N
INHALANTS (Paint, Gas, Glue, Aerosols) / Y N
MARIJUANA / HASHISH / Y N
TOBACCO / NICOTINE / Y N
CAFFEINE (Energy Drinks, Sodas, Coffee, Etc.) / Y N
OVER THE COUNTER: / Y N
OTHER SUBSTANCE: / Y N
Is child receiving alcohol and drug services: / Yes, from this program / Yes, from a different program / No
If yes, type of alcohol and drug services: / Residential / Outpatient / Community/Support
Group
LIST CLIENT’S SUBSTANCE ABUSE GOAL(S) AND ANY ADDITIONAL COMMENTS (including perceived benefits and abstinence/recovery issues):
YLO Child Initial Assessment 12/17/07 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 7 of 7
CLIENT NAME: / CLIENT MRN:Current Psychiatric Medications (check all categories that apply and list names & doses below):
0 – None
9 – Other (list): / 1 – Anti-depressants:
(Zoloft, Paxil, Wellbutrin…) / 2 – Mood Stabilizers:
(Lithium, Depakote, Tegretol…) / 3 – Anti-psychotics:
(Zyprexa, Risperdal…) / 4 – Anxiolytics:
(Xanax) / 5 – Stimulants:
(Ritalin, Adderal)
10 – History only (no current medications; list previous):
Drug Names/Dosages/Month & Year Prescribed/Physicians:
Compliance Issues? / Unknown / No / Yes / Explain:
Client’s Medical History: / Not Available / Comments:
Current Primary Medical Care Provider:
Last Physical Exam: / Within Past 12 months / More than 12 months / Unknown / No
Last Dental Exam: / Within Past 12 months / More than 12 months / Unknown / No / Explain:
Are there any health concerns (medical illness, medical symptoms)? / Unknown / No / Yes / Explain:
Non-Medication Allergies (Food, Pollen, Bee sting, etc)? / Unknown / No / Yes / Explain:
Medication Allergies?(list type) / Unknown / No / Yes / Explain:
Has the child had any of the following problems/experiences? (Check all that apply)
Asthma / Heart Problems / Surgery of any kind? / Explain:
Broken Bones / High or Low Blood Pressure / Thyroid Problem
Convulsion or Seizure / Immune System Problems / Tuberculosis (TB)
Diabetes / Liver Problems or Hepatitis / Urinary Tract or Kidney Problem
Exposure to Toxic Lead Levels / Motor or Movement Problems / Weight Gain or Loss / Explain:
Head Injury / Pregnancy / Speech of Language Problems / Explain:
Hearing Problems / Serious Rash or Other Skin Problem / Other:
Vision Problems / Sexually Transmitted Disease (STD)
CHILD, YOUTH, AND FAMILY STRENGTHS/ASSETS: / Consider Assets, Strengths, Challenges & Needs in the following areas:
· Motivation/Insight / · Social/Interpersonal
· Family / · Psychological
· Special Talents / · Emotional
CHALLENGES AND NEEDS: / · Abilities/Interests / · Community Support
· Educational / · Economic
· Vocational / · Ability to Access Care
· Cultural/Spiritual / · Needs outside system
· Safety / · Medical/Health
YLO Child Initial Assessment 12/17/07 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 7 of 7
CLIENT NAME: / CLIENT MRN:MENTAL STATUS EXAMINATION (choose at least one descriptor) Note Cultural & Age explanation for descriptors when applicable:
APPEARANCE / Normal for culture and age disheveled meticulous poor hygiene
eccentric seductive inappropriate older/younger than stated age / Comments:
ATTITUDE / engaging cooperative uncooperative angry/hostile guarded
provocative sarcastic irritable apathetic shy/timid
silly/naive manipulative dependent demanding impulsive
callous evasive sensitive tearful overly dramatic / Comments:
BEHAVIOR / Eating level: Above Normal Normal Below Normal
Energy level: Above Normal Normal Below Normal
Sleeping level: Above Normal Normal Below Normal
nightmares / Comments:
MOTOR ACTIVITY / calm/normal lethargic panicky restless, pacing repetitive
tics tremors posturing hyper-active unusual gait
Eye contact: direct/good staring evasive poor / Comments:
SENSORIUM / alert clouded confused disoriented stuporous
Orientation: person place day/date/year situation
INTELLIGENCE (by impression): average above average below average / Comments:
MOOD / euthymic (normal range) depressed (extremely sad, despondent)
sad elevated (more cheerful than normal)
irritable euphoric (exaggerated feeling of well being)
anxious / Comments:
AFFECT / broad (within normal limits) restricted blunted (severely reduced intensity)
flat (lack of affective expression) labile (rapid shifts in mood, unstable)
mood incongruent / Comments:
PERCEPTION / Within Normal Limits
Hallucinations: visual auditory other
Other Perceptual Distortions: derealization depersonalization dissociation
distortion of body image / Comments:
THOUGHT FORM/PROCESS / logical linear tangential circumstantial loose
scattered blocked fragmented flight of ideas perseverative
racing thoughts / Comments:
THOUGHT CONTENT / Within Normal Limits
Delusions: grandiose paranoid somatic jealous
erotomanic thought broadcasting other
Other Thought Distortions: obsessions compulsions hypervigilance
suspiciousness phobias magical thinking / ideas of reference
religiosity guilt sexual preoccupation / Comments:
SPEECH / Within Normal Limits incoherent halting mute
loud soft rapid pressured slurred
stammer monotone monosyllabic rambling echolalia
word salad clanging impoverished excessive profanity / Comments:
MEMORY / Remote (history, life events) Adequate Fair Poor
Recent (past 24 hours) Adequate Fair Poor
Immediate (past 5-10 minutes) Adequate Fair Poor / Comments:
CONCENTRATION / attentive distracted unable to concentrate / Comments:
JUDGMENT / Age-appropriate Fair Poor / Comments:
INSIGHT / Age-appropriate self-awareness (Understanding of own challenges and motivation)
Blames others or external factors for problems Denies illness / disability / Comments:
ABSTRACT THINKING / Age-appropriate Significant limitations Very concrete / Comments:
Summary Comments:
YLO Child Initial Assessment 12/17/07 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 7 of 7
CLIENT NAME: / MRN:LPHA DIAGNOSIS SOURCE: , Lic/Reg: /
DATE:
ICD 9 CODE: (Principle)Axis I / (Primary)
Axis I / (Secondary)
Axis II / (Primary) / Axis II / (Secondary)
Axis III