FORM # 650 COMPREHENSIVE ASSESSMENT
KEMETIC BEHAVIORAL HEALTH SERVICES COMPREHENSIVE ASSESSMENT
Name
*
First Name
Last Name
*
Social Security #
D.O.B
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicaid #:
Assessment conducted by (name and position):
Date of Onset/ Duration of Problems Developmental History Primary Diagnosis:
*
Social / Behavioral / Developmental / Family History & Support:
*
Cognitive Functioning Including Strengths and Weaknesses
*
Employment / Vocational / Educational Background:
*
Previous Interventions / Outcomes
*
Financial Resources / Benefits:
Health History and Current Medical Care Needs:
Allergies:
Recent Physical Complaints & Medical Conditions:
Nutritional Needs:
Chronic Conditions:
Communicable Diseases:
Restrictions On Physical Activities; If Any:
Past Serious Illness, Serious injury, Hospitalizations:
Serious Illnesses & Chronic Conditions of the Individual's Parent, & Siblings and Significant Others in the Same Household:
Current and Past Substance Use Including Alcohol, Prescription and Nonprescription Medications, and Illicit Drugs:
Psychiatric and Substance Use Issues Including Current Mental Health or Substance Use Needs, Presence of Co-Occurring Disorders, History of Substance Use and Abuse, and Circumstances That Increase The Individual's Risk for Mental Health or Substance Use Issues:
History of Abuse, Neglect, Sexual or Domestic Violence, or Trauma Including Psychological Trauma:
Legal Status Including Authorized Representative, Commitment, and Representative Payee Status:
Relevant Criminal Charges or Convictions and Probation or Parole Status:
Daily Living Skills
Housing Arrangements:
Ability To Access Services Including Transportation Needs:
As Applicable, and In All Residential Services, Fall Risk, Communication Methods or Needs and Mobility and Adaptive Equipment Needs:
Submit
Should be Empty: