ADAPT

BEHAVIO RAL SERVIC ES

FARS (age 18+)

Client Name:       Intake Date:       Age:    

Instructions: Complete for all clients age 18+ at admission, every 6 months & planned discharge

Current Evaluation Date:      

Purpose of Evaluation:
1=Admission 2=Every 6 months 3=Planned discharge (within 3 weeks after last session)
No Minor Needs Hospitalization Functional Assessment Rating Scale (FARS)
prob problem outpatient may be needed
treatment Domains (for clients age 18+)
1 2 3 4 5 6 7 8 9
Depression: Depressed Mood, Worthless, Lonely, Anhedonic, Hopeless, Sleep problems, Sad,
Anti-Depression Meds
Anxiety: Anxious, Guilt, Tense, Fearful, Anti-Anxiety Meds, Obsessive, Panic
Hyper-Affect: Manic, Elevated Mood, Agitated, Sleep Deficit, Overactive, Mood Swings,
Pressured Speech, Anti-Manic Meds
Thought Process: Illogical, Delusional, Hallucinating, Loose Associations, Paranoid, Ruminative,
Derailed Thinking, Loose Associations, Anti-Psychotic Meds
Cognitive Performance: Poor Memory, Low Self-Awareness, Short Attention, Developmental
Disability, Poor Concentration, Impaired Judgment, Slow Processing

Medical/Physical: Acute Illness, Chronic Illness, Handicapped/Disability, CNS Disorder, Need

Medical Care, Eating Disorder, Poor Nutrition, Enuretic/Encopretic
Traumatic Stress: Acute, Chronic, Dreams/Nightmares, Detached, Avoidant,
Repression/Amnesia, Upsetting memories
Substance Use: Alcohol, Drugs, Dependence, Abuse, Family History, Cravings/Urges, DUI, Med.
Control, Interferes with Duties, IV Drugs
Interpersonal Relationships: Poor Social Skills, Problems with friends,
Difficulty Establishing Relationships, Difficulty Maintaining Relationships
Family Relationships: No Contact, Poor Parenting Skills, Difficulty with Partner, Acting Out, No
Family, Difficulty with Relative, Difficulty with Child, Difficulty with Parent

Family Environment: Family Instability, Separation, Divorce, Single Parent, Custody Problems,
Family Legal Problems, Birth in Family, Death in family
ADL Functioning: Deficits in: Money Management, Meal Preparation, Hygiene, Transportation,
Obtain/Maintain Employment, Obtain/Maintain Housing
Ability to Care for Self: Risk of Harm, Suffers from Neglect, Not Able to Survive, Refuses to
Care for Self, Alternative Care Unavailable
Socio-Legal: Disregards Rules, Offense to Property, Offense to Persons, Conditional Release,
Probation, Pending Charges, Dishonesty, Use/Con Others
Work/School: Absenteeism, Poor Performance, Terminations, Learning Disabilities, Seeking
Employment, Illiterate, Tardiness, On Disability
Danger to Self: Suicidal Ideation, Current Plan, Recent Attempt, Past Attempt, Self-Injury, Self-
Mutilation
Danger to Others: Violent Temper, Threatens Others, Assaultive, Physical Abuser, Hostile,
Homicidal Ideation, Homicidal Threats, Homicidal Attempt
Security/Management Needs: Suicide Watch, Behavioral Contract, Seclusion, Locked Unit,
Protection from Others, Home with Supervision, Run/Escape Risk, Restraint, Involuntary
Commitment

Clinician Signature: _____________________________________________ Date:______________

Revised 10/15

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Signature/Credentials