Client Name: Client ID#: Intake Date: Age

FARS (age 18+)

Client Name: Client ID#: Intake Date: Age:

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

Revised 09/14

FARS (Clients age 18+ only)

Current Evaluation Date:

Funder on date of evaluation:

Medicaid plans: Healthy Kids plans:Other plans:

13=AHCA08=United23=Amerigroup HK49=CMS (non-Medicaid)

09=Amerigroup99=ValueOptions/First Coast114=Cenpatico HK21=FSPT CBC-CF

70=Cenpatico100=Wellcare25=United HK102=FSPT-CPC

111=Magellan113=CMS-Title 19 (Medicaid)104=Wellcare HK00=Private insurance

12=PsychCareOther: Other:

Purpose of Evaluation:

1=Admission2=Every 6 months3=Planned discharge(within 3 weeks after last session)

No prob / Minor problem / Needs outpatient treatment / Hospitalization may be needed / Functional Assessment Rating Scale (FARS)
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 10/12