History information

Client Name

DOB

Medicaid #

Phone Number

Format: (000) 000-0000.

Address

Relationship to Client

Parent Name (or Guardian)

Phone Number Of Guardian

Format: (000) 000-0000.

Client Email

example@example.com

Parent Email (if applicable)

example@example.com

Include a description of the problem(s) for which the client is currently seeking help, any relevant history of the problem(s), and any recent stressors.

Risk Assessment Mark all that applies

Rows	Yes	No
Current Suicidal thoughts
Current Suicidal Intent or plan
History of Suicidal thoughts
History of Suicidal Attempts
Current homicidal thoughts
Current homicidal intent or plan
Thoughts about committing violence
Violent behavior (people or property)
History of sexual aggression
At risk for being physically abused
At risk for being sexually abused

Client Needs assessment for Minor (Skip if does not apply) Educational Needs: Check all that applies

Are there Barriers to Learning for the Minor ( Please skip if does not apply)

Specify-what Type of Disability

Child's Behavior at school. (Please skip if does not apply)

Emotional Status(-of Minor only)

Child's Emotional is Usually

Self Care-Can the child take care of himself

SOCIAL RELATIONSHIPS (list supports)

Social skills needed to learn?

recreation/leisure activities

Family Assessment: Who does the client lives with?

Environmental stressors: (Rate 1=lowest and 10=highest)

Home

School

Community

Other/explain

Adult Case Management Assessment - if The Adult is receiving Services. EDUCATIONAL NEEDS-Check all that applies-

Housing situation

Highest Grade Completed

Need Help with the following for Housing

Medical Needs

Date of Last Primary Care Provider Check Up

Date

Sources of Income

Help Applying for the following

Mental Health Questionnaire

Substance Use and Treatment- Need help with the Follow?

Describe substance used and history

Earliest age of use

Last date used of substance

Clients Strenghts

Client strengths: Creativity Friendly Other:

Interests, hobbies, or activities the client has or would like to participate in

Client's expectations of treatment

Developmental history (include milestones and if all milestones are met in a timely manner please document within normal limits (WNL)

Social development and current ability to relate to peers

Are there any cultural concerns or possible barriers to treatment related to culture?

Community involvement and access to community resources

Current Mental Status Mood- Check one

Sexual history and orientation

Family History- Strengths and resource from family

Past Diagnosis

Family History if Substance use of Alcohol and Substance

Other

Legal/court involvement

History of domestic violence

Effect of client's condition on the family

Family members or mentors?

List current family dynamics/household members, ages, and relation to client

Describe client's interpersonal relationships with peers, adults, and persons in the community

Description of family's racial, cultural, and ethnic background

Known allergies

Hygiene/self care needs or issues

History of medical hospitalization (include dates and reasons)

Current medications (including psychotropic medicines)

Description of family's regular spiritual, religious, cultural practices

Client's/family's preference for spiritual experience

Primary Diagnosis

2. Diagnosis 2 if needed

List symptoms related to diagnostic criteria

ADMISSION ASSESSMENT

PRESENTING PROBLEM(S):

SUBSTANCE USE PATTERNS: