Initial Special Needs Assessment - Clinician
Precision Psychiatric Services
Patient's Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Date and Time of Evaluation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What is the patient's Special Mental Health Need?
Diagnosed with severe mental illness including Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, moderate to severe Major Depression, and/or Post Traumatic Stress Disorder
Developmental Delay
Gender Dysphoria
Prescribed antipsychotic medications to treat psychosis
Juveniles in adult custody
Notable difficulty adjusting to the correctional environment, even though not diagnosed with a serious mental illness (frequent readmits to suicide watch, frequent kites, frequent grievances, etc)
Other
What is the patient's baseline mental state?
What is the patient's verified treatment history?
What is the patient's housing history?
What is the patient's suicide attempt history?
Current Status/Functioning
Describe the interventions utilized/taught during the session
Current Status:
Medication Adherent?
Yes
No
N/A
Suicidal Ideations Noted?
Yes
No
Refused to answer
Homicidal Ideations Noted?
Yes
No
Refused to answer
Appearance:
Appropriate
Meticulous
Unclean
Disheveled
Other
Speech:
Appropriate
Expressive
Loud
Slowed
Pressured
Slurred
Other
Mood:
Appropriate
Depressed
Euphoric
Anxious
Angry
Irritable
Other
Affect:
Appropriate
Tearful
Blunted
Flat
Labile
Hostile
Other
Thought Process:
Coherent
Circumstantial
Tangential
Loose Associations
Poverty of Thought
Flight of Ideas
Other
Thought Content:
Appropriate
Auditory Halucinations
Visual Hallucinations
Obsessive
Delusional
Suicidal Ideations
Homicidal Ideations
Other
Orientation:
Person
Place
Time
Situation
Intelligence:
above average
average
below average
well below average
Memory:
Intact
Immediate impaired
Recent impaired
Remote impaired
Insight:
Good
Fair
Poor
Judgement:
Good
Fair
Poor
Behavior:
Appropriate
Belligerent
Agitated
Impulsive
Withdrawn
Other
Describe the patient's treatment plan and 2-3 treatment goals:
1. 2. 3.
PLAN:
Continue SN Visits
Homework given
Start suicide watch
D/C from SN program
Consult with Psychiatrist
Consult with Correctional Staff
Consult with Psychologist
Other
Follow up in ( ) days:
Referred to
Medical
Psychiatric Provider
Discharge planner
Other
Should be seen by psychiatry within ( ) days:
Housing
Intake
Restricted Housing
Mental Health Unit
GP
Other
Follow up in:
7 days
2 weeks
3 weeks
30 days
45 days
60 days
Other
Signature
Provider Name:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preview PDF
Submit
Should be Empty: