Case Management Assessment

CASE MANAGEMENT ASSESSMENT
Client Demographic Information
Client Name

First NameMiddle NameLast NameSuffix
Client DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
MCO/Private Ins.
MCO/Ins. Provider #
Medicaid #
Social Security Number
Contact Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language
Race/Ethnicity
Marital Status
Employer
Employer Address and Phone Number
Emergency Contact Name
Emergency Contact Number
Legal Guardian Information
Circle the appropriate description
Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Work Number
Client Living with Guardian
If “No”, where is client residing
Include Contact Person and their relationship.
School
Grade
Targeted Case Manager
Title/Agency: Targeted Case Manager/ K&G Counseling and Consultation
Referral Source
Name

First NameLast NameSuffix
Position/Agency:
K&G Counseling and Consultation

Address/Phone:
2530 Scottsville Rd. Suite 17, Bowling Green, KY 42104
270-598-2394
List ALL previous placements, beginning with the most recent (attach a separate sheet of paper if needed)
Date From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Placement Type/Agency Name
Outcome/Notes
Current Agency Involvement
Current Agency Names and Numbers
Previous Inpatient and Outpatient treatment (history and/or current services, type of service, date of service, provider of service and outcome)
Previous Treatment Providers - Records requested from member
Records available
If no, why?
Medication/Provider
Purpose/DX
Psychotropic Medication/Dosage
Primary Care Physician/Specialist
Address/Phone
Diagnosis
Medication
Allergies/Adverse Reactions

Area

Rows	SUMMARY OF FINDINGS: ASSESS ACROSS SETTINGS (home, school, work, community) DESCRIPTION OF IMPACT OF DIAGNOSIS OVER TIME IN EACH AREA INCLUDING HISTORY, PRESENTING PROBLEMS, AND CURRENT SYMPTOMS/NEEDS/STRENGTHS
Strengths
Natural Supports
Family Strengths
Family Reltionships/Support
Physical Health/Dental/Vision
Emotional/Mental Health/Behavioral
Social Relationships
Basic Needs: Housing, Clothing, Food, Transportation
Substance Abuse or Use
Daily Living Skills/Vocational Skills
Educational
Legal Status
Financial Resources (employment, disability, etc.)
Current Community Resources/Supports
Notes

Location of Assessment

Other
Assessment Sources
Targeted Case Manager, Signature/Credentials
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Targeted Case Manager Supervisor, Signature/Credentials
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Demographic Information

Legal Guardian Information

Referral Source

List ALL previous placements, beginning with the most recent (attach a separate sheet of paper if needed)