Tab: Assessment

Subtab: Mental Health

Assessment Date and Time

Behavior / Affect Stressors

Check all that apply Check all that apply
Appropriate Condition
Agitated Hospitalization
Anxious Diagnosis
Depressed Procedure
Crying Family Death
Fearful Family Illness
Hostile Family Problems
Help-rejecting/complaining Finances
Inappropriate Surgery
Embarrassed Unknown Causes
Evasive Abuse/Neglect
Resentful Exposure to violence
Angry Familial substance abuse
Negativistic Developmental disabilities in caregivers
Impulsive Impulsive acting out
Disturbed sleep History of DSS involvement
Nightmares History of juvenile services involvement
Night terrors Other:
Regression
Other:

Coping Consult
Check all that apply Check all that apply
Well Chaplain
Fair Social Work
Poor Psychiatry
Ineffective Child life
Other (Specify)
Cognitive Impairment Screening Present Regiment
Tool Used (Specify):
Interpretation:

Communication Coping Style

Check all that apply Check all that apply
Verbal Acting out Passive aggression
Nonverbal Affiliation Projection
Blocking Altruism Protective identification
Cimcumstantiality Anticipation Rationalization
Flight of ideas Autisitic fantasy Reaction formation
Perseveration Denial Repression
Verbigeration Devaluation Self-assertion
Neologism Displacement Self-observation
Mutism Dissociation Splitting
Acceptance Humor idealization Sublimation
Intellectualization Supression
Isolation of affect Undoing
Omnipotence
Thoughts exhibited
Check all that apply
Delusional (If chosen, check all
boxes below that apply)
Reference or persecution
Alien control
Nihilistic
Self-deprication
Grandeur
Somatic delusion
Hallucinatory (If chosen, check all
boxes below that apply)
Auditory
Visual
Olfactory
Gustatory
Tactile
Depersonalization
Obsessive
Stereotyped
 Consistent reactions
Inconsistent reactions

Reaction Level of orientation

Check all that apply Check all that apply
Over-reactive Confusion
Under-reactive Clouding of confusion
Purposeful Stupor
Disorganized Delirium
Stereotyped Acute brain syndrome
Consistent reactions Dream state, coma
Inconsistent reactions Memory disorders present

Treatment

Focused Notes