Intake CONSUMER/FAMILY PSYCHOSOCIAL ASSESSMENT

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Intake CONSUMER/FAMILY PSYCHOSOCIAL ASSESSMENT

Annual

Doctor Review Required

Name: / Case No:
DOB: / Start time: / End time: / Date:

Names/Ages/Relationship of Others in the Household:

Other Agencies/Providers Involved:

Does the Consumer Receive DHS Adult Home Health Care/Community Living Supports Services? No Yes

If yes, describe services:

How can we help you today/reason for seeking services (as described by consumer/family/other)?

What was happening in your life when you were doing better? Describe a time when life was going well.

Medical History:

Health Screen in file (even if consumer declined to complete)

All consumers will be encouraged to complete the “Exchange of Information with Primary Health Care Provider.”
Name of Primary Health Care Provider:
(Must check one of the boxes below) If consumer does not have a primary care provider:
Staff will assist consumer in connecting with a physician in their community. When this is not a viable option,
Staff will refer consumers to an urgent care facility or their local emergency room/hospital to ensure that their health needs are adequately addressed.

Medications:

Consumer/Family Assessment

/ Name: / Case No: / Page / of
History of Abusing Others: None Physical Sexual Emotional Neglect Domestic Violence
History of Being Abused: None Physical Sexual Emotional Neglect Domestic Violence
Have you ever experienced a trauma? No Yes What was the nature of the trauma?
How did the traumatic event change you or the way others view you?
Potential Risk to Staff: No Yes If yes, fill-out Assessment of Risk to Staff

Assessment of Needs 1: AFC Assessment attached—go to Assessment of Needs 2

No AFC Assessment attached, complete this section. Address each area or check &

address in the Person-Centered Plan (PCP).

In PCP
Food/Nutritional Concerns:
Physical/Health Care Concerns:
Family/Significant Relationships:
Financial Status:
Religion & Spiritual Orientation:
Employment:
Education:
Transportation:
Recreation:
Medication/Monitoring:

Assessment of Needs 2: The following are required for all consumers. Please specify action taken to

address identified need including use of natural supports, or check & address in PCP.

In PCP
Environment & Current Living Arrangement:
Clothing:
Chronic Pain:
Cultural Variables:
Military Service History:
Guardianship:
Legal:
Respite Services Explained and Offered, if appropriate:
Safety: List any ongoing safety concerns and/or risk due to consumer choice in the community, at home, or at work. Include the party responsible to meet the need and/or address safety in the PCP, if appropriate.

Consumer/Family Assessment

/ Name: / Case No: / Page / of
Crisis Plan (as appropriate): Accepted Declined
Advance Directive Acknowledgement—cannot be completed if consumer has a guardian Attached Has Guardian
Person to Notify in Case of Death:
Contact Information (PhoneNumber):

Mental Health History: Has consumer received mental health support services? Yes No

Describe relevant support services history:

Has consumer received other mental health treatment (such as hospitalization)? Yes No (if no, skip remainder of MH section)

Reason for mental health treatment:
Mental health treatment location:
This Agency Hospital Other MHC Other Type Facility Private Psychiatrist Private Therapist
Provider/Unit Name(s):
Treatment date(s) (approximate):
Treatment type: Inpatient Outpatient Intensive OP Day Tx Partial Hosp Resident Tx
Other:
Response to treatment(s):
Describe relapse history:

Substance Use Disorder History: Does consumer currently have a substance use disorder? Yes No

Has the person ever had a substance use disorder? Yes No (if no to both questions, skip remainder of substance use disorder section)

Alcohol/Drugs Used:

Alcohol / Codeine / LSD / Non-prescription Methadone / Tobacco
Ambien / Demerol / Marijuana Hashish / Over-the-counter / Percocet / Tranquilizers
Barbiturates / Heroin / Methamphetamine / Oxycontin / Prescription / Valium
Club Drugs (Ecstasy, GHB) / Morphine / PCP / Steroids / Xanax
Cocaine/Crack / Inhalants / Other:
SUBSTANCE USED: / Current Use Past Use
Pattern of Use: / Continuous Episodic Binge Other, describe:
Amount Used:
Most Recent Usual Route of Entry into the Body: Oral Smoking Inhalation Injection Other
Age First Used (enter “99” if Newborn. For alcohol, enter age of first intoxication):
Current Frequency of Use:
No use past month 1-3 times per month 1-2 times per week 3-6 times per week Daily
Frequency of Use During the 6 Months Prior to Assessment:
No use past 6 months 1-3 times per month 1-2 times per week 3-6 times per week Daily
Has consumer ever received treatment for a substance use disorder? Yes No
Total Number of SUD Treatments (if greater than 99, enter “99”):
SUD treatment location:
This Agency Hospital Other MHC Other Type Facility Private Psychiatrist Private Therapist
Provider/Unit Name(s):
Treatment date(s) (approximate):
Treatment type: Inpatient Outpatient Intensive OP Day Tx Partial Hosp Resident Tx Detox
Other:
Response to treatment(s):
Describe relapse history:
Is Methadone planned: None Planned Yes, Planned

Consumer/Family Assessment

/ Name: / Case No: / Page / of
SUBSTANCE USED: / Current Use Past Use
Pattern of Use: / Continuous Episodic Binge Other, describe:
Amount Used:
Most Recent Usual Route of Entry into the Body: Oral Smoking Inhalation Injection Other
Age First Used (enter “99” if Newborn. For alcohol, enter age of first intoxication):
Current Frequency of Use:
No use past month 1-3 times per month 1-2 times per week 3-6 times per week Daily
Frequency of Use During the 6 Months Prior to Assessment:
No use past 6 months 1-3 times per month 1-2 times per week 3-6 times per week Daily
Has consumer ever received treatment for a substance use disorder? Yes No
Total Number of SUD Treatments (if greater than 99, enter “99”):
SUD treatment location:
This Agency Hospital Other MHC Other Type Facility Private Psychiatrist Private Therapist
Provider/Unit Name(s):
Treatment date(s) (approximate):
Treatment type: Inpatient Outpatient Intensive OP Day Tx Partial Hosp Resident Tx Detox
Other:
Response to treatment(s):
Describe relapse history:
Is Methadone planned: None Planned Yes, Planned
SUBSTANCE USED: / Current Use Past Use
Pattern of Use: / Continuous Episodic Binge Other, describe:
Amount Used:
Most Recent Usual Route of Entry into the Body: Oral Smoking Inhalation Injection Other
Age First Used (enter “99” if Newborn. For alcohol, enter age of first intoxication):
Current Frequency of Use:
No use past month 1-3 times per month 1-2 times per week 3-6 times per week Daily
Frequency of Use During the 6 Months Prior to Assessment:
No use past 6 months 1-3 times per month 1-2 times per week 3-6 times per week Daily
Has consumer ever received treatment for a substance use disorder? Yes No
Total Number of SUD Treatments (if greater than 99, enter “99”):
SUD treatment location:
This Agency Hospital Other MHC Other Type Facility Private Psychiatrist Private Therapist
Provider/Unit Name(s):
Treatment date(s) (approximate):
Treatment type: Inpatient Outpatient Intensive OP Day Tx Partial Hosp Resident Tx Detox
Other:
Response to treatment(s):
Describe relapse history:
Is Methadone planned: None Planned Yes, Planned

Consumer/Family Assessment

/ Name: / Case No: / Page / of

Other Addictions (i.e., gambling, sexual, etc.)—Identify and describe current/past treatment:

(Unless initial appointment) Satisfaction with services & goals to date – use direct quotes from consumer:

(Updated annually) Progress in achieving dreams, desires, goals & objectives identified in the Person-Centered Plan, including evidence (include description of progress made on each goal and outcome whether they are met, continued, unchanged, modified, or discontinued. Include rationale for extending goal beyond duration of service anticipated in last service):

Clinical Impression (if assigning a diagnosis):

ICD-9 Billing Diagnosis: / DSM-IV Diagnosis (include diagnostic code number and nomenclature):
Axis I: / Axis II:
Axis III (as reported by consumer):
Axis IV:
Axis V: / Indicate Primary (P), Secondary (S) or No (N)
CAFAS: / MI / DD
Substance Use Disorder (SUD): / 2 Does not have an SUD / 3 Not evaluated for SUD
4 At least one SUD either active or in partial remission (use within past year)
5 All coded SUDs are in full remission (no use for 1 year)
6 Results from screening or assessment suggest SUD

Does this represent a change in diagnosis? No Yes. If yes, provide rationale, including evidence:

Physician’s diagnosis and clinician’s diagnosis are reviewed for consistencies. Yes No N/A. If no, explain:

Report completed by: / Date Completed:
Credentials:
Physician’s Signature: / Date: