Assessment Notes:

Date of Assessment:

Client Name (last name, first name):

Marital Status:

Single Never married Married Separated

Date of Birth:

Ethnicity:

Is Client an Adult or Minor: Adult = 18 + Minor = 0 – 17 years old

Primary Caregiver: For minors, document the name of the parent, family member, CWS, foster Care,
Conserved, individual who has legal responsibility for minor.

Gender: Male or Female (as it appears on legal birth certificate)

Address: (Current)

Veteran: Yes = has served in the military. No = has not served in the military.
Unknown = Consumer has no recollection/knowledge or consumer was not
asked this question.

Client’s Preferred Language:

Family’s Preferred Language:

Client’s Primary language:

Interpreter Offered:
If yes- Interpreter name:
First Name-
Last Name-
Agency-
B. Presenting Problems

Presenting Problem – Chief Complaints:

Anxiety Depression Substance Abuse Hallucinations

Impairment ADLs
Eating Problem Hyperactive Difficulty Concentrating Suicidal Ideation Academic
Problems Obsessions/Compulsion Delusions Trauma Paranoia
Sleeping Problem Oppositional Aggressive Symptoms/
Irritability
 Other:

Presenting Problem – Chief Complaints Comments (Client/Caregiver Statement) :

(In the client’s own words/ Clients’ caregivers words)
Why are they here?

What services do they want/expect to receive?

Ct reported “____________________” for the last _____________ months/years. Ct reported

symptoms of (symptoms here) ______times per week since ________ months ago.

*Guide them in learning/expressing their Mental Health need(s).

Be Realistic – Mental Health Wise. Ex: “stop the voices, be able to work
without being depressed.”

History of Present Illness (including recent stressors and precipitation events):

 Previous hospitalizations?
 Behaviors?
 Changes in life (breakups, death, eviction, etc) and when?
 Other stressors?

C. Psychosocial Factors

Psycho-Social History:
Document client’s life-
where client grew up?

siblings, parents, family dynamics (family member with/disability or challenges)

education (IEP, suspensions, grades, discipline actions, friends)

alcohol or drug use (age started, choice of drug/alcohol)

physical/emotional abuse (by whom, CPS, foster care)

Legal Status:
None Voluntary 5150 DTS 5150 DTO 5150 GD Conservatorship Juvenile Hall
Custody Hold Probation Parole Other Unknown

Legal History: Explain; Arrests (why, outcome/status/dates), Probation, Parole, In-

formal probation, divorce, pending court dates, child custody, child welfare
issues
Highest Grade Completed:

Employment Status:
How many days of school did the client miss in the last 6 months? If client is in school, indicate the number of
school days the client has missed in the last 6 months (estimate is okay) Complete only if in school

How many days of work did the client miss in the last 6 months? If client is currently employed, indicate the
number of school days the client has missed in the last 6 months (estimate is okay). Complete only if employed

How many days in the past 6 months has the client been incarcerated? Document the number of
days the client has been in jail, prison, juvenile hall within the last 6 months (estimation
is okay)

Education and Employment Comments: Document name of current school and grade level, not
currently enrolled, highest grade completed: HS Diploma, GED, some college, obtained
any degrees, (IEP, suspended, expelled, dropped out)

Document name of employer/company (job title, how long at job), full time or part time.
Currently not currently employed or never worked. Laid off, fired or quit; when & why?
Financially sustained by SSI, GR, Veterans compensation, Unemployment, ect.

Living Situation:
Home Apartment Board and Care Room and Board Trailer Hotel Homeless

Living Situation Comments:

With who?
How long? Near eviction? Temporary?
Supportive, tense, hostile environment?

Social/Relational Functioning comments:

How does the client engages/relates to others?
friends (lots/little/none)
good/poor social skills, introvert, extrovert, pushy, shy, easily/difficulty in maintaining friends, dating, bullied,
the bullier If “none”write non-reported

D. Mental Health History

Previous Treatment/Hospitalizations:
Denies Inpatient Chemical Dependency Inpatient Psychiatric Hospitalization
Detox Treatment Outpatient Chemical Dependency Outpatient Psychotherapy
Self-Help Group Support Other
Previous Treatment Comments: Summarize the checked boxes
Document any past mental health counseling include name of agency, reason, dates if
known (year if known), outcome, effective or not, relapses, ect.
If “none” write non-reported

Other Collateral Information: Document services with Conservatorship, CWS, Foster

Care, Probation, Parole, attends AA or NA groups.

E. Developmental History

Developmental History (i.e. crawling, walking, talking, etc.):

Document attainment of significant milestones such as walking, talking, and toilet training in a timely manner.

Significant Perinatal History: Include perinatal, prenatal early developmental

history, drug exposure, abuse, premature birth history, ect.
For children and adolescents document: perinatal, prenatal early developmental
history, complications at birth, drug exposure in utero, premature birth history, in
NICU for any period of time, parental relations)

Cs reported-
Cs caregiver reported-

□ No information available. Explain

Ex: “consumer is a poor historian”, “consumer was in foster care since age
of 6 and has no
developmental history information”

F. Physical Health
Physical Health Issues, Allergies;
Yes = client has physical Health Issues or Allergies No = client has no physical Health Issues or
Allergies Unknown =client is not aware of any physical Health Issues or Allergies
Sleep Disturbance: (nightmares, night terrors, insomnia)
Yes = client has sleep disturbance No = client has no sleep disturbance
Unknown = client is not aware of any sleep disturbance
Appetite Disturbance: (bulimia, anorexic, decrease/increase appetite)
Yes = client has Appetite Disturbance No = client has no Appetite Disturbance
Unknown = client is not aware of any Appetite Disturbance
Physical Health Comments: Document the client’s physical health Issues and Allergies
Health Disorders: cancer, leukemia, diabetes, heart attack, knee replacement,
acid reflex, kidney stones, dialysis, shunt, wears glasses, deaf, hearing aid
Is client currently linked to a Primary Care Physician?
Yes = client has a primary care physician No = client has no primary care physician
Name of Primary Care Physician:

Name of Doctor and/or Clinic-

Regularly = regular checkups/taking care of self/ for preventative appointments and when ill/needed
 Intermittently = going to doctor now and then but only as needed
Crisis only = only when really sick or injured
Never = does not go to doctor/ has never had a PCP

Current Medications:
Yes = client is currently taking prescribed medications
No = client is not currently taking prescribed medications
Unknown = client does not know or is unwilling to answer if he/she is taking prescribed medication

Current Medications Comments (including medical marijuana and methadone maintenance):

List all (prescribed and over the counter) medications consumer is taking, current
dosage/frequency, prescribing MD, when started the medication, for what, how
long taking medication.

If “none”, write: non-reported

Medication Allergies:
Yes = client has medication allergies No = client has no medication allergies
Unknown = client does not know if he/she has any medication allergies
Medication Allergies Comments:
Document what consumer is allergic to and adverse reactions.
Ex: allergic to Tylenol; throat swells up and unable to breathe.
If “none”, write: non-reported

Strengths
What personal, family and community resources/strengths can be used to
support this client in treatment?
There are many types of “culture” that the consumer has that will help consumer to
move forward with their recovery.

Ct could benefit from:

Religion: name of religion, frequency of attendance, level of involvement, spiritual

practices
Ex: “I am a Christian, I go to church every Sunday and I am part of the woman’s group
that meets monthly”, “I am a Jehovah Witness and I do not believe in celebrating worldly
holidays”, “I am Agnostic and believe in a higher power”, “I am a devout Catholic and
attend church every Sunday”, “I believe in a higher power and worship at in the privacy
of my own home”.
Traditions: holiday’s celebrated, family gatherings (weekly/monthly/annually)
Ex: “I participate in family traditions (walk down Xmas tree lane, birthday parties, annual
reunions)”, “We get together every Sunday and have dinner.”
Customs/Beliefs: voodoo, herbs, cultural rituals,
Ex: “I don’t take medications only natural remedies, I believe in homeopathy”, “I go to a
Curandero when I get sick.”
Community: Local Clubs or groups
Ex: “I am in recover so I attend AA/NA meetings and have friends there and a sponsor”,
“I participate in Gay parades and attend LGBT groups.”
Other: Personal interests, Immigration
Ex: “I practice mindfulness meditation.”, “I belong to a book club because I like to read
and talk about it”, “I belong to a bike club and we ride together.”

Client/Family Strengths:
Document Consumer’s strengths to achieve therapeutic goals including internal and
external strengths to achieve therapeutic goals.
Guide them in identifying positives such as good attendance in school/work,
communication skills,
resourceful, specific family member, friend(s), church, stable income of GR/SSI.

Clinician Rating of Client’s Support System:

Using your clinical judgement, select one rating that best supports the client’s support
system.
1 – None: Client has no support system at all
2 – Some: Client may have one or two support persons, group or club but doesn’t use
utilize them
3 – Adequate: Client has at least three or more supports and utilizes them at
times/sometimes
4 – Good: Client has several or more support systems and utilizes them as needed
5 – Excellent: Client has many supports systems and utilizes them often
Abuse History:
None Reported Neglect Physical Sexual Emotional Financial Other Unknown

Abuse Comments (include whether or not CPS/APS and/or law enforcement report was filed):
Document description of the abuse checked boxes (neglect, emotional, sexual, physical,
or financial abuse.

Document clients age when it occurred.

Was there arrests/interaction with the legal system (court, Foster Care, Group Home,
CPS, APS, perpetrator was sentenced, investigation was unfounded) If “none”, write
non-reported

Ex: Consumer and his/her siblings were removed from parent’s home when 11 years old
by CPS. Father and mother were arrested for physical & sexual child abuse. Parents were
sentenced to 8 years in prison. Consumer has had no contact with parents to date.
Consumer has not seen siblings since being removed from the home.

Danger to Self: Check the appropriate boxes the client/caregiver is providing.

None: Has NO suicidal ideation/thoughts of hurting self
 Denies Ideations: Client denies having any thoughts of committing suicide/self-injurious tendencies
Ideations: Client has thoughts of suicide/hurting self only (they think about it but that’s all)
Rumination: Client is considering/contemplating committing suicide or self-injury.
Impulses: Client acts upon thought of committing suicide; acting in the heat of the moment – take pills,
run out in traffic, hanging, gun, ect. Note: Those acting on impulse are most likely to be successful in
ending their life.
Intent: Client has aim, purpose, goal or deliberate act of committing suicide/self-injury.
Plan: Client has developed a plan how to end their life/commit suicide; has means, place, time or a trigger
of when to commit suicide.
Prior Attempts: Client has at least one attempt or more to commit suicide.
Self Injury: Client engages in cutting, burning, pinching, biting, carving, branding self, punching walls,
banging head on walls, swallowing sharp object or harmful substances, ect.
Danger to Self Comments: Document description, clarification or more information of
the “danger to self” boxes checked.

Ct reported-

Gravely Disabled:
Danger to self can also include a situation where the client is unable to care for their own nourishment, shelter
or self-protection.
If “none”, write Ct Denied or reported none

Danger to Others: Check the appropriate boxes the client/caregiver is providing.

None: Has NO thoughts of hurting anyone.
Denies Ideations: Client denies having any thoughts of hurting others/anyone.
Ideations: Client has thoughts of hurting someone only
Rumination: Client is considering/contemplating hurting someone
Impulses: Client impulsively would act upon a thought of hurting someone without thinking.
Intent: Client has aim, purpose, goal or deliberate act of hurting someone. TARASOFF
Plan: Client has developed a plan of who, when and how he/she is going to hurt someone. TARASOFF
Prior Attempts: Client has at least one attempt or more to hurt someone.

Danger to Others Comments: If “none”, write Ct Denied or reported none

Document description, clarification or more information of the “danger to others”
boxes checked.
Document if TARASOFF (duty to warn) is/will be done.
Ex: although client reports only having suicidal thoughts, client reports having
access to his father’s gun.
Ex: Reported TARASOFF by contacting Fresno Police Department and roommate
of client’s threat/plan.
Additional Risks: Document if there are any other risks the client is reporting/presenting with

Ex: Client is sharing needles, having unprotected sex, multiple sex partners, having sex in full knowledge
of a diagnosis of HIV/AIDS/STD, ect.

Substance Abuse
Past and present use of tobacco, alcohol, caffeine, complementary alternative medicine, over-the-
counter drugs, and illicit drugs?
Check the appropriate boxes the client/caregiver is providing.
Yes = client is currently and/or has in the past used tobacco, alcohol, caffeine, complementary
alternative medicine, illicit drugs, or over-the-counter drugs.
No = client is not and has never used tobacco, alcohol, caffeine, complementary alternative
medicine, illicit drugs, or over-the-counter drugs.
Possibly = client could currently be using and/or have a history of past used tobacco, alcohol,
caffeine, complementary alternative medicine, illicit drugs, or over-the-counter drugs. (may appear
to under the influence but is denying, reports a short time of use but denies abuse/dependence
Unknown = client does not know or unable to recall of using tobacco, alcohol, caffeine,
complementary alternative medicine, illicit drugs, or over-the-counter drugs currently or in the past.

Comments on past and present substance use: If “none”, write non- reported
Document any and all types of substances used, frequency, duration and status (abuse, dependence,
remission).
Include: cigarettes, +vapors/e-cigarettes, medical marijuana card, pain
medications, huffing, melatonin, Benadryl, sleep aids, cough syrup
Describe (age of onset, drug of choice, last use, frequency of use, periods of
sobriety, how long using, relapses?): drug of choice.

Note: if box is checked, did it land in Dx? If no, In Remission or does not impair
client? It can be a Risk Factor.

Mental Status Exam

General Appearance: Check the appropriate boxes that describes client’s general appearance right now.
Well-Groomed = filthy/dirty clothes, unkempt, distinguishing (e.g., scars, tattoos). Is there any evidence of
self-neglect? Immaculate, clean shaven, good hygiene, attention to detail, nails clean
Appears Stated Age = looks their stated age
Weight Appropriate = weight appears within normal range
Within Cultural Norms = appropriate for setting, season, gender,
 Bizarre = odd or eccentric clothing or accessories
Body Odor = bad or foul smelling
Appears Younger = looks younger than stated age
Appears Older = looks older than stated age
Overweight = appears over weight / obese
Underweight = looks underweight, thin
Disheveled = being in loose disarray; unkempt, as hair or clothing; untidy
Alcohol on Breath = smells of alcohol and or marijuana
Other = average built, husky, tall, position relaxed/rigid
General Appearance Comments:
Ct was observed to_______________ as evidence by_________________________
Ex: Consumer was not dressed appropriately for the hot 99 degree weather as evidence of consumer wearing
coat and a hat, was malodorous and wearing soiled and stained clothing, appears to be overweight and
appears stated age.

Behavior:
Within Cultural Norms = informal understandings that govern the behavior of members of society;
expectations, rules that guide behavior
Engaging = pleasant, agreeable, likable
Calm = relaxed, tranquil, an unruffled state
Cooperative = involving mutual assistance in working toward a common goal, collaborative, willing to be
helpful
Intrusive = invading personal space, becomes too involved or comes too close without being invited
Stereotyped Activity =
Catatonic = apparently awake, but unresponsive
Withdrawn = not wanting to communicate with other people, introverted, unsociable, reclusive, inhibited
Dominating = have a commanding influence on, exercise control over, to control
Belligerent = hostile, threatening, aggressive, confrontational, combative
Threatening = having a hostile or deliberately frightening quality or manner, showing an intention to cause
bodily harm, causing someone to feel vulnerable or at risk
Uncooperative = unhelpful, stubborn, contrary, inflexible
Inappropriate = not suitable or proper in the circumstances, improper, unbecoming
Provocative = arousing sexual desire or interest deliberately, seductive, suggestive, alluring
Superficial = appearing to be true or real only until examined more closely, on the surface
Hyperactive = abnormally or extremely active, showing constantly active and sometimes disruptive behavior,
displaying exaggerated physical activity,
Immature = not fully developed, having or showing emotional or intellectual development appropriate to
someone younger
Aggressive = ready or likely to attack or confront, hostile, pushy, forceful
Behavior Comments:
Summarize consumer’s behavior (describe consumer’s behavior; as evidence by? Describe what do you see?)

Relatedness Toward Examiner:

Cooperative = involving mutual assistance in working toward a common goal, collaborative, willing to be
helpful,
Dominating = have a commanding influence on, exercise control over, to control
Guarded = cautious, having possible reservations, wary, reserved, noncommittal, reluctant
Belligerent = hostile, threatening, aggressive, confrontational, combative
Engaging = pleasant, agreeable, likable
Defiant = resistant, obstinate, uncooperative, noncompliant
Uncooperative = unhelpful, stubborn, contrary, inflexible
Hostile = unfriendly, malicious, vicious, unkind, mean
Superficial = appearing to be true or real only until examined more closely, on the surface
Inappropriate = not suitable or proper in the circumstances, improper, unbecoming
Suspicious = having or showing cautious distrust of someone or something, doubtful, questionable
Threatening = having a hostile or deliberately frightening quality or manner, showing an intention to cause
bodily harm, causing someone to feel vulnerable or at risk
Provocative = arousing sexual desire or interest deliberately, seductive, suggestive, alluring
Evasive = elusive, vague, unclear, tending to avoid commitment
Aggressive = ready or likely to attack or confront, hostile, pushy, forceful
Other =

Relatedness Toward Examiner Comments:

Summarize how the consumer related to you (describe the consumer’s interaction with you; as evidence by…)

Interpersonal Relationships: Check the appropriate boxes that describes client’s current interpersonal
relationships with others.
Adequate Social Skills = ability to communicate and interact with people verbally & non-verbally; ability to
make & keep friends
Age Appropriate Group = friends are within their own age;
Supportive Relationships = having family, friends, peers, colleagues
Overly Shy = extremely shy, a marked increased or excessive feelings of being uncomfortable, self-conscious or
nervous,
Poor Social Skills = interact awkward, weird, or in an odd manner, seem emotionally immature, difficulty
making or keeping friendships, display inappropriate behavior
Problems With Friends = being taken advantage of/used, being pressured to do things
Difficulty Establishing Relationships = uncomfortable around people, lack of social skills,
Difficulty Maintaining Relationships = unable to keep relationships
Other = Decision making skills, assertiveness skills, problem solving skills, listening skills

Interpersonal Relationships Comments: Summarize consumer’s interpersonal relationship

Speech:
Normal for Culture = communication or expression of thoughts in spoken words/in correct usage
Spontaneous = unrehearsed, unplanned, uninhibited, easy
Elaborates = provides clarification, explains
Pressured = too fast, difficult to interrupt, frenziedly as if motivated by an urgency not apparent to the
listener
Rapid = fast pace, accelerated
Slowed = slow pace
Loud = (volume/tone) is strong, demanding, screaming
Slurred = prolonged, jumbled, responses trail off
Over productive = talking excessively, responses are above and beyond/providing too much
Word Salad = incomprehensible speech due to lapses in connections even within a single sentence;
incoherent, a “tossed salad” of ideas
Tics = sudden, repetitive vocalization
Soft = (volume/tone) nearly inaudible, whispering, shy
Poverty = alogia, reply sparsely, fail to answer, responses are very brief
Mute/Underproductive = silent, not talking, no response
Stutter/Stammer = some words are repeated and others are proceeded by “um” or “uh”
Mumbled = say something indistinctly and quietly making it difficult for others to hear
Other =

Speech Comments: Provide a summary of the consumer’s speech

Mood:
Happy = cheerful, giddy, ecstatic, joyful
Euthymic = a feeling of well-being, tranquility, calmness; consistent emotional expression
Calm = peaceful, without worry, at rest
Angry = bad mood, cranky, annoyed, argumentative, aggressive,
Irritable = feeling of agitation, frustrated, easily upset
Defensive = justifying their actions or words, trying to protect themselves
Sad = unhappy, sorrowful, down, gloomy, melancholy
Dysphoric = a profound state of unease or dissatisfaction, a negative feeling especially about life in general,
unhappy
Depressed = feeling sad, inactivity, difficulty in thinking and concentration, feelings of dejection and
hopelessness
Anxious = worried, concerned, uneasy, apprehensive, fearful, perturbed, distressed, disturbed, agitated, edgy
Panicky = feeling or characterized by uncontrollable fear or anxiety
Worried = anxious perturbed, troubled, concerned, overthink, brood, fretful,
Elevated = raise (up), increased
Tense = tight, rigid, uneasy, apprehensive, antsy, strained
Expansive = forthcoming, sociable, friendly, outgoing, chatty, talkative,
Euphoric = intense feelings of well-being, elation, happiness, excitement, and joy
Bored = uninterested, dullness,
Shy = bashful, reserved, mousy, insecure, embarrassed
Mood (additional options):
Responsive to Caregiver = cooperative, hostile
Other =

Mood comments: Provide a summary of the consumer’s mood

Affect:
Broad = normal; expression of emotion or feelings displayed to others through facial expressions, hand
gestures, voice tone, and other emotional signs such as laughter or tears
Labile = rapid & abrupt shifts in affective expression, usually unprovoked changes in emotional expression,
excessive displays of emotion or expression that are not congruent with the situation
Blunt = a person’s emotional responses are less intense or as strong as they should be, feelings and reactions
are reduced in comparison to a normal response.
Flat = no emotional expression or response; absence of appropriate emotional response for a given situation
Fluctuating = change, shift, altering
Tearful = in tears, with tears in one’s eyes, choked up
Congruent = emotion corresponds to the content of speech & thought
Incongruent = emotion displayed does not match speech, thought or context accompanying it, inappropriate
Restricted/Limited = Constricted/Inhibited = decreased or diminished in spontaneity
Other = irritable

Affect Comments: Provide a summary of the consumer’s affect; give an example to boxes checked

Orientation:
Person = ability to identify one’s name
Place = ability to name where they are; what building, city or state
Time = date, day of week, year, season
Situation = ability to describe their global circumstances ex: “I came to the ER”
Other =

Orientation Comments: Provide a summary of the consumer’s orientation to support checked boxes

Perception – Delusions:
Denies = Consumer reports having no delusions
Paranoid = suspiciousness, persecutory trends, anxiousness due to inability to trust others,
Grandiose = belief that one possesses special powers, wealth, skills, belief they have amazing abilities
Religious = belief of having a unique and privileged relationship with “The Almighty.”
Persecutory = belief that someone or some group is conspiring against them by cheating, spying, harassing or
gossiping about them or even attempting to poison or drug them.
Nihilistic = belief that one is dead or empty or that there is some impending event (Ex: the world is ending)
Somatic = can refer to a variety of physical experiences (Ex: rising experience, knot in my stomach, ache in my
heart), belief that one’s body is somehow strange or not functioning properly, belief they may have some
internal bug or parasite that is destroying or affecting some very specific part of their body.
Other = Erotomanic; belief a famous or important person is seriously in love with them. Thought broadcasting;
delusion that one’s thoughts are being broadcast out loud so that they can be perceived by others. Thought
insertion; belief one’s own thoughts are not one’s own, but rather are inserted into one’s own mind.

Perception – Hallucinations:
Denies = Consumer reports having no hallucinations
Auditory = Hearing voices or noises no one else hears
Visual = seeing people, things or shadows that no one else sees
Olfactory = smelling an odor that is not actually there, inhaling a real odor but perceiving it as different scent
than remembered
Command = a voice that one hears and it tells the listener what to do
Tactile = bodily sensations, something is felt on the skin in the absence of a physical stimulus
Gustatory = sensation of taste, usually unpleasant, without an actual stimulus
Other =

Perception – Distortions:
Denies = Consumer reports having no distortions
Depersonalization = feeling detached from, and as if one is an outside observer of one’s mental processes,
body, or actions (feeling like one is in a dream, a sense of unreality of self, perceptual alterations, emotional
and/or physical numbing; temporal distortions; sense of unreality)
Derealization = feeling detached from, and as if one is an outside observer of, one’s surrounding (e.g.,
individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
Illusions = distorted perception of something not actually present
Other =

Perception Comments: Provide a summary of the consumer’s perception - distortions

Estimated Intelligence:
Above Average = using big vocabulary words
Average = a good general ability of reasoning and problem solving abilities. Impression based on vocabulary
usage.
Below Average = struggling to form sentences
Unable to Estimate = non-verbal; refusing to talk

Intelligence Comments: Provide a summary of the consumer’s intelligence

Thought Flow: (the quantity, tempo (rate of flow) and form (or logical coherence) of thought.
Logical = consistency in reasoning, sensible, rational
Goal-Directed = flow of ideas, symbols and associations initiated by a problem or task and leading toward a
reality-oriented conclusion in logical sequence, focused on a set goal
Focused = ability to stay on topic and does not stray to other related topics.
Coherent = logically consistent; connected; able to think or express one’s thoughts in a clear or orderly
manner
Rational = logical, reasoned, sensible, sound, prudent, intelligent
Loose Associations = shift abruptly from one thought to another with little or no connection, total loss or
disintegration of connectedness in conversation and thought
Flight of Ideas = rapid succession of ideas or their overt expression (some logical connection between thoughts is
retained)
Tangential = sudden change from one topic of conversation to another (less severe than loose associations)
Circumstantial = irrelevant detail, unnecessary detail, of no primary significance; incidental; talking at length
around a subject before finally getting to the point
Disoriented = confused, unable to think with normal level of clarity
Illogical = what the person is saying does not make sense, contradicting, irrational, unreasonable, nonsense
Circular Reasoning = is a logical fallacy in which the reasoned begins with what they are trying to end with.
The components of a circular argument are often logically valid because if the premises are true, the
conclusion must be true.
Incoherent = lacking connection; unable to think or express one’s thoughts in a clear or orderly manner
Poverty of Ideas = person keeps returning to the same limited set of ideas
Irrational = unreasonable, illogical, groundless, unfounded, baseless
Other =

Thought Flow Comments: Provide a summary of the consumer’s thought flow

Thought Content:
Normal = usual, typical or expected
Homicidal = Desire to do serious harm to or take the life of another person.
Ideas of Reference = Delusions where one interprets innocuous events as highly personally significance (e.g. A
woman rarely leave her house, because she experiences all conversation or laughter she hears as directed at
herself.).
Obsessions = persistent, often unwanted, intrusive thoughts that cannot be suppressed
Helpless/Hopeless = weak, powerless, feeling despair about something
Suicidal = Desire to harm oneself or end one’s life, considering or planning to kill self/commit suicide
Blames Others = placing blame on other people
Guilt = a sense of blame, responsibility for imagined offenses
Magical Thinking = The erroneous belief that one’s thoughts, words, or actions will cause or prevent a specific
outcome in some way that defies commonly understood laws of cause and effect. Magical thinking may be a
part of normal child development.
Sexual Preoccupation = obsession, grossly consumed with sexual fantasy, often in combination with obsessive
pursuit of casual or non-intimate sex; pornography; compulsive masturbation
Phobias = irrational, intense, persistent fears of such items as dogs, heights, elevators, insects, leaving home,
closed spaces, and flying; they will go to great lengths to avoid the situation or object of the phobia.
Worthless = feeling of no value, good-for-nothing
Suspicious = mistrustful, disbelieving, skeptical, suspect,
Other =

Thought Content Comments: Provide a summary of the consumer’s thought content (give examples)

Memory – Immediate Recall: ability to learn new material, to retain and store information, to acknowledge
and register any sensory input, and to retrieve or recall stored material.
Memory – Short Term: temporary and capacity-limited (seconds or minutes); delays rapidly
Memory – Recent: ability to recall events that have happened in the last few hours or days before coming in
to see you (what they had for lunch, where parked the car)
Memory – Remote/Long-Term: permanent (days to years), no evident limits on storage capacity (ask about
personal events in their lives and commonly known public events that happened in years past)

Memory Comments: Provide a summary of the consumer’s thought content (give examples)

Abstraction: how well a person thinks abstractly or how well they deal with similarities (use proverbs such as
“A stitch in time saves nine” or “Two wrongs don’t make a right”.) Have them tell you what it means and judge
how their reply.
Interpretation: an explanation by client in understandable terms regarding symptoms or mental
condition and in explaining matters
Judgment: refers to a person’s problem-solving ability in a more general sense. Can be evaluated by exploring
recent decision-making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out
of a house?).
Insight: acknowledgement of a possible mental health problem. Understanding of possible treatment options
and ability to comply with these.

Abstraction Comments: Provide a brief summary of the consumer’s abstract thought (give examples)

Diagnosis and Disposition

Type of Diagnosis: admission = initial update = biannual/update

Clinical Summary / Comments (include provisional and rule-out information):

Important and basic demographic and psychosocial information to start.

Include presentation (affect, orientation, appropriately/poorly groomed,
disheveled).
Include symptoms consistent with the DSM diagnosis (Dx), showing that
the client meets the criteria for that diagnosis according to the
diagnostic guidelines listed in the DSM. You have to be able to justify
your DSM Dx in the summary. Make sure that you have written out
every single DSM Criterion required from the DSM. It is good practice to
keep your DSM handy or look up the Dx on the computer to make sure
every single criteria is listed on your summary.

Include the onset/duration of symptoms.

Include the frequency and intensity of symptoms. Try to include

triggers.

Include a baseline of experiencing symptoms based on a 7 day period.

Here is an example of what it can look like.

Client is a _____ year old (Hispanic, Caucasian, etc) male,

(single,married), who came into the session with his (mother, sister, or
alone), with (no, 1,2,3+) children. Client presented with (blunted, flat,
appropriate) affect. Client was (well, poorly) oriented to
(time,place,person,context). Client was adequately/poorly groomed as
evidenced by (body odor, unshowered, messy hair, dirty clothes; neat
clothing/hair, makeup).

Client reported mental health symptoms began (xx) years/month ago,

and has increased in severity in the last (xx) period of time.

Client reported experiencing (depression,anxiety,psychosis) 7x days per

week. Cs reported the symptom was severe/moderate/mild, and
occurred (all day, mornings, nights only). Cs reported symptom (ie,
depression) with symptom list (sad feelings, isolation, HI/SI, poor sleep,
irritability, fatigue, etc).

ALWAYS include this at the end (if it is true): Client denied any current
SI/HI. Include any risk factors.

Or……Why do they not meet medical necessity?

First/Primary Diagnosis:
Status of Diagnosis 1:
Second Diagnosis:
Status of Diagnosis 2: active, resolved, rule out, …, in remission,
Third Diagnosis:
Status of Diagnosis 3:
Fourth Diagnosis:
Status of Fourth Diagnosis:
Fifth Diagnosis:
Status of Diagnosis 5:

General Medical Conditions (CSI): Check the boxes of medical conditions reported.
Trauma: check the appropriate box
Referrals: indicate any referrals needed/made
Medical Necessity: check the appropriate boxes
Area(s) of Impairment: check the appropriate boxes
Comments on Medical Necessity and Impairments:

Due to mental health symptoms of: depression with x, x, x, x and anxiety with
x, x, x, x, and x, Client experiences impairment in daily living, living
arrangement, social and family relationships, employment/academic, and
health functioning due to / as evidenced by, Client being unable to (ie, sustain
social relationships, having family conflicts, being unable to maintain a job,
being expelled from school, neglecting physical health, neglecting personal
hygiene or ADLs [activities of daily living], having marital conflict, etc).

Billing Dates and Duration

Billing Data: the clinician may enter more than one date when working on the assessment to note
service minutes spent on working on it. Sometimes this may occur such as when gathering collateral
information from both parents, teacher, or other providers on different dates.
Billing Date: indicate the date of service
Practitioner: Select your name
Service Code: Assessment Code
Service Duration: Length of time to do assessment
Doc and Travel Duration:
Total Service Duration:
Program: select your program
Location: select where service took place
Evidence-Based Practices / Services Strategies (CSI): select appropriate boxes (we can select Assertive
Community Treatment for all or the clinician can select whatever EBP may be used during course
of Tx. Does not need to match Tx Plan.)

Leave in
Final February 12, 2018