Anywhere School Health Center

Address

Phone

Behavioral Health Services - Child/Adolescent Assessment

Student’s Name: D.O.B: Grade: ____

Referred by: Chart #: ______

Chief Complaint (Reason for Referral/Presenting Problem):

 Academic Behavior Peer Relationships Family Relationships

 Substance Abuse Physical/Sexual Abuse Other Stressors

Living Situation:

 Both biological parents One parent Step parent in home

 Grandparent(s) Foster parent Juvenile home

 Other:

Other persons living in home:

Who has legal custody:

School Academics/Behavior:

 General Studies Vocational Special Education/Remedial Class

 Alternative Program Retained in Past Suspensions/Detentions

 Problems with teachers Problems with peers

 Other/Comments:

Favorite classes and why:

Least favorite classes and why:

Academic Performance: Outstanding Satisfactory Failing

Previous Academic Performance: Outstanding Satisfactory Failing

Substance Use:TobaccoCaffeineAlcoholMarijuanaCocaine

AcidRX pillsOther:

Age of first use: Frequency:

Patient thinks substance abuse is a problem for him/her: Yes No___

Alcohol/Substances have been a problem for other family members: Yes No___

Medical History/Medications:

Mental Health Services/Medications:

Other services patient is involved in: DHHR Other Counseling Services

Social/Community/Interests & Hobbies:

 Has many friends Has best friend Has friends over to home

 Spends time at friend’s home Attends community functions

Leisure Interests:

Sexual Behaviors/Issues:

Sleep Patterns:

Has difficulty sleepingYes No If yes, patient displays:

 Nightmares Frequent waking Early morning wake-up

 Excessive time falling asleep Insomnia Night terrors

Weight or Food Issues: Overweight Underweight Satisfied with weight/body image

Patient Name: Chart #:

Strengths and Resources:

Assessment/Preliminary Diagnosis:

Treatment Type: Individual Family  Group Frequency:

Solution Focused Therapy Homework given Support

Insight Family Education

Behavioral Relationship Resource Linkage

Cognitive Problem Solving Advocacy

Additional Comments:

Plan/Homework:

MENTAL STATUS/BEHAVIORAL ASSESSMENT

Conversation:

 Relevant  Free Flowing  Irrelevant  Guarded Rambling

 Other

Affect:

 Flat  Blunted Appropriate  Labile  Broad  Restricted

 Inappropriate

Mood:

 Normal Euphoric  Euthymic  Elated Depressed  Anxious

 Irritable Expansive Dysphoric Other:

Mood and Affect:

 Congruent Incongruent

Speech:

 Soft Loud Pressured  Audible  Inaudible

 Rapid Slurred Slow Stuttering  Other:

Psychotic Symptoms:

 None Auditory Hallucinations Visual Hallucinations

 Tactile Hallucinations Olfactory Hallucinations Other:

Thinking:

 Appropriate  Loose Associations  Flight of Ideas  Slow  Delusional

 Ideas of Reference Preoccupied  Homicidal  Suicidal  Disoriented

 Poor Concentration

Behavior and Manner:

 Cooperative  Established Rapport Polite and Courteous  Sociable

 Eye Contact  Uncooperative LOA  Rude  Evasive

 Posture  Fidgety Lethargic  Easily Distracted

 Short Attention Span Intrusive Talkative Oppositional Behavior

 Aggressive Behavior Fine Motor Coordination Gross Motor Coordination

Appearance:

 Appropriate  Clean Neat  Casual  Formal  Untidy

 Glasses  Visual Problems  Hearing Problems  Motor Problems

 Appearance in relation to age:  Clothing style:

Reviewed limits of confidentiality  Parental Consent in chart

Scores from Objective Survey (HAD, CDI, Connors, etc.)

Children’s Developmental Questionnaire:  Yes No  N/A

Issues from GAPS Screening:

Counselor: Date: ______

WV School Health Technical Assistance and Evaluation Center1/18/07

Marshall University Sample MH assessment form.doc

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