Pre-Screening Evaluation

PRE-SCREENING EVALUATION

I.IDENTIFYING DATAChart #: ______

Clinician: ______CMHC: ______

Location of Interview: ______Date: ______Time: ______

Referred By: ______Requested Level of Care: ______

Client: ______Medicaid #: ______

SS#: ______DOB: ______Age: ______Sex: ______Race: ______

Address: ______

Phone #: ______County of Residence: ______

Legal Guardian: ______

Address: ______

Screening Informant(s): ______

______

II. PRESENTING PROBLEM (Indicate current problems which may require treatment.)

______

III.TREATMENT HISTORY

Inpatient Treatment (Including Substance Abuse Treatment)

Facilities and Dates: ______

Outpatient Treatment (Including Substance Abuse Treatment)

Facilities and Dates: ______

Current Medications: ______

Prescribed By: ______

Other important treatment history: ______

______

History of involvement as juvenile offender: ______

IV.MENTAL STATUS AND CLINICAL ASSESSMENT

PHYSICAL HEALTH:

Hearing Impaired Physically Handicapped

Visually Impaired Other Impairments: ______

Known Medical Problems/Allergies: ______

GENERAL APPEARANCE:

Neat Appropriately Groomed Unkempt/Disheveled Seductive

Clean Appears Older Poor Hygiene/Self Care Underweight

Appropriately Dressed Appears Younger Eccentric Overweight

MOOD:AFFECT:

Cooperative Fearful Irritable Primarily Appropriate Blunted

Calm Suspicious Guilty Primarily Inappropriate Flattened

Cheerful Tearful Hostile Restricted Labile

Anxious Pessimistic Dramatized Detached

Depressed Euphoric

SPEECH:

Normal for Age and Intellect Rapid Logical/Coherent

Rambling/Tangential Developmentally Delayed Slow/Sparse

Soft/Mumbled/Inaudible Pressured Loud

THOUGHT CONTENT/PERCEPTIONS:

Delusions Auditory Hallucinations Flight of Ideas

Paranoid Disorganized Bizarre

Grandiose Obsessive Other Hallucinatory Activity:______

Visual Hallucinations Circumstantial______

BEHAVIOR/MOTOR ACTIVITY:

Normal Repetitious TicsPoor Eye Contact

Agitated Overactive/Hyperactive Manipulative Tremors

Compulsive Alert Peculiar Mannerisms Slowed

Tense

ORIENTATION:INSIGHT:MEMORY:

Time Good Impaired Recent

PlaceFair Impaired Remote

Person Poor Adequate

Lacking

Superficial

REALITY CONTACTS:

Intact TenuousPoor Lacking

INTELLECTUAL ASSESSMENT:

Above Average Below Average Documented MRIQ Score ______

Average Possible MR

V.ASSESSMENT OF RISK

Within the past 48 hours, behavior presents an imminent life-threatening emergency (describe):

______

Suicide/Homicide AttemptCurrent By History

With Plan:______

With Intent:______

With Method:______

Denies suicidal/homicidal ideation, intent, or plan.

Plan of rescue included in attempt (describe):______

Self-MutilationCurrent By History

Describe:______

______

Unprovoked AggressionToward Adults Toward Children Current By History

Describe:______

______

Episodes of incapacitating depression/psychosis resulting in ability to function/care for basic needs.

Describe:______

______

Substance Abuse/Misuse/DependenceCurrent By History

Describe:______

______

Property Destruction/Fire SettingRecent By History

Describe:______
______

Cruelty to AnimalsRecent By History

Describe:______

Family history of mental Illness (describe):______

______

Family history of substance abuse (describe):______

______

Victim of Abuse

Sexual Abuse:______

Physical Abuse:______

Emotional Abuse:______

Neglect:______

Sexual Perpetrator:______

VI.ASSESSMENT OF EXISTING SUPPORT SYSTEMS

Has Does Not HaveA support system available (e.g. family, guardian, friends, teacher, etc.)

Please specify:______

Has Does Not HaveA stable living environment.

OVERALL DIAGNOSTIC IMPRESSION

Axis I:______

Axis II:______

Axis III:______

Axis IV: Problems With Primary Support Group⃞Educational Problems

Problems Related to Social Environment Occupational Problems

Problems with Access to Health Care Services Housing Problems

Problems Related to Interaction with the Legal System/Crime Economic Problems

Other Psychosocial and Environmental Problems

Axis V: Current______Highest in Past Year ______

VII.DISPOSITION

Diverted from Hospital Admission to:______

Family/Guardian/DHS/OJA Case Worker was Offered Case Management Services.

Case Management Referral to:______

Voluntary Admission Acute Care TFC

Involuntary Admission RTC Substance Abuse Detox

DenialLevel of Care:______

OVERALL ASSESSMENT OF CHILD'S CURRENT NEED FOR TREATMENT (Including the reason for denial, if the child does not meet medical necessity criteria.) ______

______

______

______

______

______

______

______

______

______

Use back of form if additional space is needed.

______

Signature & Credentials of Mental Health ProfessionalDate

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pcop/forms/clinical/EOC/emer- child prescreen eval.doc 9/29/11 File: Emergency/Gatekeeping Tab