History information

Client Name
DOB
Medicaid #
ADMISSION ASSESSMENT
Phone Number
Address
Relationship to Client
Parent Name (or Guardian)
Phone Number Of Guardian
Client Email
example@example.com
Parent Email (if applicable)
example@example.com
PRESENTING PROBLEM(S):
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

IEP504 PlanStruggle with readingSmall class sizeStruggle with MathIssues with Social SkillsBecomes Angry A lotNeedy
Are there Barriers to Learning for the Minor ( Please skip if does not apply)

Learning DisabilityIntellectual DisableHomelessnessLanguage BarrierMental Health Disability
Specify-what Type of Disability
Child's Behavior at school. (Please skip if does not apply)

Defies parentsAttacks othersCreates disruptionRuns AwayProvoke SiblingsSets FiresAccess weaponsSeeks Negative PeersSexually inappropriateDemands attentionSuicidal ideationsOCDSelf mutilationSleep issuesAnxietyDepressedTantrumsHyperactivity/ restlessCries a lotEating disorderLiesSteals
Emotional Status(-of Minor only)

Always get in troubleattention seekertardy for school or classesUnder AchievesTruantPoor peer relationshipfights others
Child's Emotional is Usually

HappySadAngry
Self Care-Can the child take care of himself

YesNo
SOCIAL RELATIONSHIPS (list supports)
Social skills needed to learn?
recreation/leisure activities
Family Assessment: Who does the client lives with?

Bio ParentsBio MotherBio FatherLive with SiblingsFoster ParentsOther
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-

Vocational helpGEDCollege ClassesJob CorpsTraining ProgramHelp with Job search
Housing situation

HomelessApartmentHousingSection 8Living with others
Highest Grade Completed

Middle SchoolHigh SchoolSome CollegeCollegeMasters or Higher
Need Help with the following for Housing

Locating Help for electric/LGEWater billsRental helpOther UtilitiesSeasonal help-Christmas Thanksgivings
Medical Needs

primary care providerDentistOBGYNPsychiatristNutritionistAllergistSleeping ConcernsOptometrist
Date of Last Primary Care Provider Check Up

MonthDayYear
Date
Sources of Income

JobSSDI or SSDIUnemploymentKtapChild Support
Help Applying for the following

JobsSSDI or SSISection 8 or other HousingApplying for school or help child to transferFood StampsWICFirst time mother help or baby needsFood sheltersHomeless ShelterClothing or school needs for self or children
Mental Health Questionnaire

Testing for DisabilitiesMedication needsPast suicidal ideationHospitalizationsAnxietyDepressionMood disorders
SUBSTANCE USE PATTERNS:
Substance Use and Treatment- Need help with the Follow?

Drug Counseling12 steps ProgramCenter stone for rehabLandmark Recovery
Describe substance used and history
Earliest age of use
Last date used of substance
Clients Strenghts

CreativityCuriosityHonestyDeterminedrespectfulForgivenessLovingFriendlyHumorousSelf-AssuredTrustworthyLeaderFairIntelligent
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

AnxiousAngryEuphoricDepressedNormal
Sexual history and orientation
Family History- Strengths and resource from family

Seeks Resource from familyseeks help from supportOpen to helpMotivated with serviceopen to ChangeInvolve in treatmentSupportiveOther
Past Diagnosis

BipolarMajor DepressionBorderline personality disorderEating disorderGeneralized anxiety disorderPhobiaOCDADHD (any type)PTSDSchizophreniaDissociative identity Disorder
Family History if Substance use of Alcohol and Substance

Alcoholprescription MedicationStreet DrugsOther
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
Should be Empty:

ADMISSION ASSESSMENT

PRESENTING PROBLEM(S):

SUBSTANCE USE PATTERNS: