First Session / Transition of Care

First Session / Transition of Care
Client:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Transferring / Most Recent MHS/MHP name:
Date of last session

MonthDayYear
Date
Date of most recent Assessment*

MonthDayYear
Date
List all current Diagnosis*
What services has the client received in the last 30 days?*
What are the client’s current symptoms and the precipitating factors (significant occurrences that preceded/brought about or triggered the presenting problem and its consequences) and perpetuating factors (features that sustain and possibly reinforce clients’ current)?
Describe how the client’s mental health symptoms impact their day-to-day functioning in a variety of roles and settings. Identify the major life domains where there is a functional impairment impacted by the client’s mental health symptoms.
How has the client’s symptoms changed (improved or deteriorated) since their last service or assessment? What are the barriers (causes that explain the progress)?
Strengths: What are some personal qualities that you have that would help you in services? Check all that apply and list other that not shown above

I have the ability to ask for helpI have a good support system/recovery environmentI have a good relationship with my family and friendsI am dependableI have integrityI am a good listenerI am well-liked by othersI am organizedI am patientI am courageousI am motivatedI am goal-orientedI take care of my physical healthI am financially stableOther
Need's: What do you want to learn in services? What skills would help you improve your overall functioning? Check all that apply and list other that are not shown.

An explanation of my diagnosisImprovement in my communication skillsImprovement in my interpersonal skillsConflict Resolution skillsContact with supportive othersEmotion-management skillsAnger-management skillsPersonal safety planParenting skillsEducation about improving my healthMedication management skillsTime Management skillsGrief Management skillsImprove my relationships with othersImprove my social skillsIncrease my academic performanceOther
Abilities: What are some of your personal qualities, skills or talents that will help you in services? Check all that apply and list other that are not shown.

I am very motivated for treatmentI have a stable recovery environmentI have good ADLs and IADLsI have good interpersonal skillsI have good emotion-management skillsI have demonstrated openness and honesty regarding mental health challengesI have some insight into my mental health challengesI have good self-esteemI have some positive plans and goals for my futureI have a good spiritual healthIn spite of past hardships, there are still areas of my life in which I take pleasureI am a caring person, capable of offering support to othersOther
Preferences: What do you hope to get out of services? Check all that apply and list other that are not shown.

I will learn the skills to get a better understanding of my diagnosisI will learn the skills to communicate more effectivelyI will learn the skills to improve my interpersonal skills/relationshipsI will learn the skills to develop a system of suppportI will learn the skills to manage my emotions, thoughts and behaviorsOther
Medication Information (as applicable)
Name of the prescribing physician:
Date of last psychiatric evaluation /follow up:

MonthDayYear
Date
Reason for client assignment or transition of care:
Current Provider name*
Provider email address*
example@example.com
Credentials*
(LPC, LCSW, PLPC, LMFT, MHS, MHP, etc)
Date of submission*

MonthDayYear
Date
Signature*

Clear
LMHP Name
LMHP Credentials
(LPC, LCSW, PLPC, LMFT, MHS, MHP, etc.)
LMHP Signature

Clear
Should be Empty: