MENTAL HEALTH PLAN ASSESSMENT FORM

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MENTAL HEALTH PLAN ASSESSMENT FORMEvery item must be completed.DateProviderPhoneProvider Office AddressClient Name D.O.B. SSNConsent to treat given by: Self Parent/Guardian ConservatorReferral Self School Probation Court CPS APS Parent/Guardian/Conservator Access Unit OtherLiving Arrangement Own House Bio FamilyEthnicityEmergency Contact Foster Family Group Home SNF B&CLanguage Preferred for ServicesRelationshipPhoneAddressPresenting Problem (nature and history)REV. 3. 2016Page 1 of 6

MENTAL HEALTH PLAN ASSESSMENT FORMRisk AssessmentCurrent harm to self-risk N/A Ideation Intent Plan MeansDescribe:History of:Current harm to others risk N/A Ideation Intent Plan Means:Describe:History of:Describe: (note if a particular person is at risk)Assaultive/Combative No YesIf yes, describe:At risk of abuse or victimization No YesDescribe:Have all mandated reporting requirements been met?Yes, by : Yes, by this Provider No (Explain)Other:Client StrengthsREV. 3. 2016Page 2 of 6

MENTAL HEALTH PLAN ASSESSMENT FORMClient Name:Culture/Diversity: Assess unique aspects of the client, including culture, background, and sexualorientation, that are important for understanding and engaging the client and for care planning.Preferred language for receiving our services:Culture client most identifies with:Problems client has had because his/her cultural background:Sexual orientation issues: None NoneSupport/ involvement of family in client’s life: Desire of client involvement of family or others in treatment: DesiresPsychiatric History (Medication(s) and dosage (current))Medication(s) (past):History of Mental Illness in FamilyPrior Hospitalization(s) No YesPrior Outpatient TreatmentREV. 3. 2016 No YesIf yes, describe:If yes, when, where No YesIf yes, when and with whom:Page 3 of 6

MENTAL HEALTH PLAN ASSESSMENT FORMClient Name:Medical History Health Problems (current) No YesHeight:Weight :Sleep Disturbance No YesIf yes, describe:Appetite Too Little Too Muchlbs. Weight Loss:lbs. Cognitive Describe:Describe:Adverse response to medicationsREV. 3. 2016(Mandatory if client is a MINOR)Weight gain:Disability Developmental PhysicalAllergies No YesIf yes, describe: No YesIf yes, describe:Page 4 of 6

MENTAL HEALTH PLAN ASSESSMENT FORMSubstance Use/ allucinogensCocaine/CrackHeroinPrescription MedsOther:No UseFrequencyMental StatusAppearance:Orientation:Speech:Thought Process:Thought Content:Perceptual Process:Last Use dOrganizedThought BlockingPoor ConcentrationNormalOtherNormalVisual sAppropriateFlatIntactRecent MemoryProblemAverage None Cognitive Deficits PresentConcentration Deficits Present Insight:Judgment:Mood:Affect:Memory:Estimated IntellectualFunctioning:Cognitive Deficits:REV. 3. 2016Amount Well-groomed Inappropriate clothingPlace Disoriented CoherentMumblingCoherent Flight of IdeasObsessiveDelusional Auditory hallucinations Other Average DirtyTimeRapidTangentialGrandiose Poor Average HopelessIrritableDepressed LabileSadManic InappropriateBlunted TearfulImmediate Memory ProblemRemote Memory Below Average PoorAbove AveragePage 5 of 6

MENTAL HEALTH PLAN ASSESSMENT FORMClient Name:Impairments requiring Mental Health Treatment:Dysfunction Rating NoneDescribe how symptoms impair functioning:Employment/ Education:Competitive job market, 35 hours or more per Mild Moderate SevereOccupation:Rehabilitative work, less than 20 hours per week Competitive job market, less than 20 hours per week. School, full time Volunteer Work Retired Rehabilitative work, 35 hours or more per week Not in Labor force Job training, full time Part-time school/job training Highest Grade completed Resident/InmateweekFull-time homemaking responsibilityUnknownMedical Necessity**** Qualifying mental health diagnosisQualifying impairment is an important area of life functioningProbability of a significant deterioration in an important area of life functioning(Children only) Probability that child will not progress developmentally as individually appropriateEPSDT – QualifiedPlanned interventions will address impairment conditionsClient is reasonably expected to benefit and improve with respect to impairmentsCondition would not be responsive to physical health care-based treatment*All asterisked items must be present, plus 1 more and must be supported by documentation in recordOther Providers/ Agencies client is involved with:Signature of ProviderDatePrinted NameREV. 3. 2016Page 6 of 6

MENTAL HEALTH PLAN ASSESSMENT FORM REV. 3. 2016 Page 1 of 6 . Every item must be completed. Date Provider Phone Provider Office Address_ Client Name _ D.O.B._SSN_ Consent to treat given by: Self Parent/Guardian Conservator . Referral Self School Probation Court CPS APS Parent/Guardian .

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