Initial Assessment Form - Clinician
Precision Psychiatric Services
Patient Name
Date of Evaluation
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Current and Previous Diagnoses:
Current: Previous:
Charges:
Booking Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Incarcerations?
Yes
No
Unknown
Past incarcerations details:
Hx of Sexual Offense?
Yes
No
Unknown
Details of Sexual Offense:
Current Employment:
Unemployed
Employed
On Disability
Other
Employment Details:
Previous Employment:
Highest Education Achieved:
Special Education?
Yes
No
Unknown
Other
Housing Status:
Homeless
Lives with Family
Lives with Spouse
Room and Board
Board and Care
Other
Family History of Mental Illness:
Religion/Spirituality
Military History?
Yes
No
Unknown
Military History
Type of Discharge
Honorable
Dishonorable
Medical
AWOL
Other
History of Psychiatric Hospitalizations
Yes
No
Unknown
Other
Psych Hospitalization History:
Number of hospitalizations: Last hospitalized: Locations:
Current Outpatient Mental Health Treatment?
Yes
No
Unknown
Other
Outpatient treatment details:
Clinic name and Location: Last appointment: Provider name(s):
Currently Prescribed Medications?
Yes
No
Unknown
Other
Current Medications:
Previous Medication Trials?
Yes
No
Unknown
Other
Previous Medications:
Current Psychosis?
AH
VH
Tactile
Delusions
None
Psychosis Details:
History of TBI/Head Trauma?
Yes
No
Unknown
Other
TBI Details:
History of abuse or victimization?
Yes
No
Unknown
Other
Type of Abuse:
Emotional
Sexual
Physical
Other
Abuse Details:
History of Violent behavior?
Yes
No
Unknown
Other
Violent behavior details:
Prior Mental Health Court?
Yes
No
Unknown
Other
Prior or current guardianship?
Yes
No
Unknown
Other
Past Suicide Attempts or Self Harm?
Yes
No
Unknown
Other
Suicide Attempt/Self Harm Details:
When last: Details: Previous events:
Current thoughts of SI or Self Harm?
Yes
No
Unknown
Other
Plan?
Yes
No
Unknown
Plan details:
Current thoughts of HI?
Yes
No
Unknown
Other
HI Details:
Concerns about ability to cope in jail?
Yes
No
Unknown
Other
SUBSTANCE USE HISTORY
ETOH
Heroin
Cocaine
Crack
Meth
THC
Other Opioids
Other Stimulants
PCP
Spice or Bath Salts
None
ETOH Frequency + last use date
Heroin/Opiates Frequency + last use date
Cocaine + last use date
Crack Frequency + last use date
Meth Frequency + last use date
THC Frequency + last use date
Other Opioids Frequency + last use date
Other Stimulants Frequency + last use date
PCP Frequency + last use date
Spice or Bath Salts Frequency + last use date
History of Withdrawals?
Alcohol Withdrawals
Opioid Withdrawals
None
Other
History of Withdrawal Seizures?
Yes
No
Unknown
Other
Thoughts of suicide during withdrawals?
Yes
No
Unknown
Other
Inpatient Substance Abuse Treatment (Rehab)?
Yes
No
Unknown
Other
Rehab details:
Outpatient Substance Abuse Treatment History?
Yes
No
Unknown
Other
Outpatient SUD treatment details:
History of Medication Assisted Treatment?
No
Suboxone
Methadone
Naltrexone/Vivitrol
Other
MAT treatment history:
Willing to participate in SUD program and treatment?
Yes
No
Unknown
Other
Suicide Risk Assessment:
Historical or Genetic Static Risk Factors
Male Gender
Past Suicide Attempt
Family/Significant history suicide
Childhood trauma
Terminal/incurable medical illness
Age (Adolescent/Elderly)
Military veteran
Domestic violence charge
Current incarceration is first incarceration.
Current charges involve crime against a child.
Current charges suggest long sentence possibility
Prior suicide watch placement in facility.
Recent release from Inpatient Psychiatric Facility
Other
Protective Factors
Engaged in mental health treatment
Spouse, family, friend support
Children at home
Feels responsibility to care for others
Has insight into problems/issues
Has defined future goals/plans
Religious beliefs prohibitive against suicide
Engaged Collaborative Safety Plan and Reasons for Living
Employed
Enrolled in MAT program
Fear of death/dying/pain/suffering
Modifiable Risk Factors (patient reported):
Feeling helpless or hopeless
Feeling guilty or worthless
Recent loss of family/social support
Anniversary of an important event (death, arrest, birthday, etc)
Financial difficulties/loss of job due to incaceration
Newly diagnosed illness
Negative visit/phone call/recent bad news
Humiliating event (sexual assault)
Other
Modifiable Risk Factors (observed):
Unwilling to engage with MHP
Currently intoxicated
Mood disorder diagnosis
Psychotic disorder diagnosis
Substance use diagnosis
Impulsive/aggressive
Current segregation status
High profile crime
New legal issues
Poor compliance with treatment/medications
Current withdraw protocol
Anxious, agitated, or fearful of safety
Symptoms of psychosis
Symptoms of depression
Symptoms of mania
Borderline personality disorder
Reports of concerning statements and/or behaviors
Other
Current Acute Self-Harm/Suicide Risk
Low
Intermediate
High
Recommend Safety Cell Placement?
Yes
No
INITIAL DIAGNOSIS/IMPRESSION:
Follow Up Plan:
Treatment not indicated at this time; educated on how to further access services. MH staff to follow up PRN
Complete Suicide Watch Initial Assessment and start suicide watch.
Begin Collaborative Safety Planning.
MH with follow up
Homework given
Consult with Psychiatrist
Consult with Psychologist
Consult with Correctional Staff
Other
Follow up in:
2 weeks
3 weeks
30 days
45 days
60 days
Other
Housing recommendation
Other Recommendations:
Refer to
Psychiatric Prescriber
Discharge Planner
Medical/Nursing
Substance use counselor
Special Needs
Other
Should be seen by psychiatry within ( ) days:
Signature
Completed by (Name):
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