Legal Status and Special Populations

Provider: / Out of Area COUNTY______
Mental Health Plan / Coordinator:
Program: / Phone:
Cost Center-Reporting Unit: / CHILD & YOUTH COMPREHENSIVE
ASSESSMENT / Fax:
Program Admit Date: / Date Completed: / Minutes:
Requested AUTHORIZATION / START DATE: / END DATE:
CLIENT NAME: / Sex:
M F / DOB: / Age Today: / Client MRN:
SSN:
CAREGIVER: / Phone: / Relationship:
Address: / City: / Zip:
LEGAL GUARDIAN: / Phone: / Relationship:
Address: / City: / Zip:
REFERRAL SOURCE: / CWS/CPSSchool PhysicianParent / Caregiver
TherapistProbation SelfOther / Phone: / Contact:

LEGAL STATUS AND SPECIAL POPULATIONS:

VoluntaryDep. of Court (300 W&I)Alta Regional Ctr. 26.5/ AB3632
Foster ChildOn Probation (600 W&I)Aid to Adoptive Parent(s) Other / Comments:
Language spoken most frequently in the home (check only one):
1 - Cambodian / 4 - Hmong / 7 - Lao / 10 - Romanian / 13 - Spanish / 16 - Tongan
2 - Cantonese / 5 - Japanese / 8 - Mandarin / 11 - Russian / 14 - Tagalog / 17 - Vietnamese
3 - English / 6 - Korean / 9 - Mien / 12 - Samoan / 15 - Thai / 18 -

FUNCTIONAL IMPAIRMENT PRESENTING PROBLEMS / TARGETED SYMPTOMS / REASONS FOR SERVICE:

Functioning(Please assess how current symptoms have effected the level of impairment in the following categories and indicate anticipated impairment at discharge)

Impairment Level (Circle One for Each identified Category) / Anticipated Impairment at Discharge
Categories / None / Mild / Moderate / Marked / Extreme / (E.g., “2”)
Problems w/primary Support / 1 / 2 / 3 / 4 / 5
School Performance due to Mental Health Issues
(Note Level and check if other categories are applicable) / 1 / 2 / 3 / 4 / 5
□ Truant □ School suspension □ AB3632
Friendship/Peer Relationships / 1 / 2 / 3 / 4 / 5
Self care/daily activities / 1 / 2 / 3 / 4 / 5
Depressive Symptoms / 1 / 2 / 3 / 4 / 5
Mania/Agitation/Lability Symptoms / 1 / 2 / 3 / 4 / 5
Physical Health Status/Somatic Disturbances / 1 / 2 / 3 / 4 / 5
Oppositional to following directions / □ school / 1 / 2 / 3 / 4 / 5
□ home / 1 / 2 / 3 / 4 / 5
Appetite disorder/Sleeping Disturbances (circle) / 1 / 2 / 3 / 4 / 5
Anxiety/Phobia/Panic Attacks / 1 / 2 / 3 / 4 / 5
Interaction with legal system due to Mental Health Issues / 1 / 2 / 3 / 4 / 5
Ability to Concentrate/Attention/Cognition/Memory/Thought / 1 / 2 / 3 / 4 / 5
Ability to Control His/Her Temper/Affect Regulation/Impulsivity / 1 / 2 / 3 / 4 / 5
Destructive/Assaultive / 1 / 2 / 3 / 4 / 5
Problems related to socialization/Communication / 1 / 2 / 3 / 4 / 5
Perceptual Disturbances (Hallucination, Delusions, Paranoia…) / 1 / 2 / 3 / 4 / 5
Other: / 1 / 2 / 3 / 4 / 5

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / CLIENT MRN#:
PROBLEM AREA ASSESSMENT / FUNCTIONAL IMPAIRMENT:
Rate the following problem areas. Problems marked “Severe” must be followed up on immediately. Provide details in the PRESENTING PROBLEMS section and an action plan in the SUMMARY section on page 6.

PROBLEM AREAS:

/ History (past)
Yes No / Severity of Problem in last 2 months (current)
None Insignificant Mild Moderate Severe / Potential Risk (immediate future, up to 60 days)
None Insignificant Mild Moderate Severe
1. Self-harm (e.g., cutting, head banging, high risk behavior)
2. Suicidal ideation/behavior
3. Violence (e.g., fighting, aggression, physical assault)
4. Homicidal ideation/behavior
5. Psychiatric hospitalization / crisis services
6. Loss of placement
7. Runaway
8. Physical abuse
9. Sexual abuse
10. Domestic violence / violent environment
11. Legal trouble
12. Drug or alcohol abuse
13. Addictive behaviors (e.g., eating, dieting, gambling, etc.)
14. Academic (or job) trouble
15. Perpetration of sexual assault or sexual acting out
16. Destruction of property or vandalism
17. Fire setting
18. Gang activity or association
19. Isolation, rejection by peers, compulsive or odd behavior / belief
20. Enuresis / encopresis
21. Cruelty to animals
22. Other problem area (specify):
PSYCHOSOCIAL HISTORY (Check below and circle how it applies to all that apply below, as appropriate)
Category / None/Unk
Family involvement in current problem / None / some support / moderate / Very supportive
Family Interpersonal relationships (including parents and siblings) / None / Explain:
Divorce/Remarriage/Blended Family / None / Explain:
Level of acculturation / None / mild / moderate / severe / Fully integrated
Family acculturation-Generational differences / None / mild / moderate / severe / Fully integrated
Language issues / None / Non-English / Limited English / Bilingual / Literacy Level limited
Immigrant/Refugee Experience / None / (<1 yrs) / (<2 yrs) / 1st Generation / 2nd Generation
Family Living situation and stability / None / Unstable / Stable / Explain:
Experiences of discrimination / None / once in awhile / Frequent
Chronic or Terminal Illness/Death of Caregiver / None / Who? / Explain:
Family History of Alcohol/Substance Abuse History / None / Who? / Explain:
Familial Criminal Justice Involvement / None / Who? / Explain:
Family History of Abuse / Physical / None / Who? / Explain:
Sexual / None / Who? / Explain:
Emotional / None / Who? / Explain:
Family Mental Health History / None / Explain:
Family Suicide/Suicide Attempt/ Unexplained Death / None / Who? / Explain:

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / CLIENT ID#:
CLIENT’S MENTAL HEALTH HISTORY: / INCLUDE:

Earliest symptoms
Age at onset
Family understanding of the problem
Other supports/stressors at the time of onset
Response to treatment
Other potential contributing factors

Yes No Previous outpatient mental health services? When/where? Transfer
Yes No Previous crisis contact? Number of crisis unit visits without hospitalization in past 6 months: 0 1 2 or more Most recent date:
Yes No Previous psychiatric hospitalization? Number of psychiatric hospitalizations in past 6 months: 0 1 2 or more Most recent date:
Number of days hospitalized in the past 6 months:
Yes No Use of traditional or alternative healing practices (describe, with results):
SUBSTANCE USE/ABUSE (Please answer the following questions about all current drug and alcohol use.) List applicable drug(s) for items marked “True”:
1. / True False Drinking or drug use sometimes causes me to miss school, work, or important appointments.
2. / True False I sometimes drink or use drugs when it is dangerous to do so.
3. / True False I sometimes have problems with the police or school authorities due to my drinking or drug use.
4. / True False I sometimes drink or use drugs even though they cause problems in my life.
5. / True False I need more to get drunk or high now than I used to. (Tolerance)
6. / True False Trying to quit makes me sick; I get withdrawal symptoms. (Withdrawal)
7. / True False I sometimes end up drinking or using more than I meant to.
8. / True False I have tried to quit before, but failed. (Give approximate dates for each applicable drug.)
9. / True False I spend more and more time getting and using drugs/alcohol.
10. / True False I sometimes choose drugs or alcohol over friends and family.
11. / True False I keep using even though the drug/alcohol makes me sick or messes with my mind.

TYPE OF SUBSTANCE

PRENATAL EXPOSURE

AGE AT FIRST USE

CURRENT SUBSTANCE USE

Check if ever used:
ALCOHOL / Unknown / None/ Denies / Current
Use / Current
Abuse / Current
Dependence / In Recovery / Client-perceived Problem?
Y N
AMPHETAMINES (Speed/Uppers, Crank, Ritalin) / Y N
COCAINE / CRACK / Y N
OPIATES (Heroin, Opium, Methadone) / Y N
HALLUCINOGENS (LSD, Mushrooms, Peyote, Ecstasy) / Y N
SLEEPING PILLS, PAIN KILLERS, VALIUM, OR SIMILAR / Y N
PCP (PHENCYCLIDINE) OR DESIGNER DRUGS (GHB) / Y N
INHALANTS (Paint, Gas, Glue, Aerosols) / Y N
MARIJUANA / HASHISH / Y N
TOBACCO / NICOTINE / Y N
CAFFEINE (Energy Drinks, Sodas, Coffee, Etc.) / Y N
OVER THE COUNTER: / Y N
OTHER SUBSTANCE: / Y N
Is child receiving alcohol and drug services: / Yes, from this program / Yes, from a different program / No
If yes, type of alcohol and drug services: / Residential / Outpatient / Community/Support
Group
LIST CLIENT’S SUBSTANCE ABUSE GOAL(S) AND ANY ADDITIONAL COMMENTS (including perceived benefits and abstinence/recovery issues):

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / CLIENT MRN:
Current Psychiatric Medications (check all categories that apply and list names & doses below):
0 – None
9 – Other (list): / 1 – Anti-depressants:
(Zoloft, Paxil, Wellbutrin…) / 2 – Mood Stabilizers:
(Lithium, Depakote, Tegretol…) / 3 – Anti-psychotics:
(Zyprexa, Risperdal…) / 4 – Anxiolytics:
(Xanax) / 5 – Stimulants:
(Ritalin, Adderal)
10 – History only (no current medications; list previous):
Drug Names/Dosages/Month & Year Prescribed/Physicians:
Compliance Issues? / Unknown / No / Yes / Explain:
Client’s Medical History: / Not Available / Comments:
Current Primary Medical Care Provider:
Last Physical Exam: / Within Past 12 months / More than 12 months / Unknown / No
Last Dental Exam: / Within Past 12 months / More than 12 months / Unknown / No / Explain:
Are there any health concerns (medical illness, medical symptoms)? / Unknown / No / Yes / Explain:
Non-Medication Allergies (Food, Pollen, Bee sting, etc)? / Unknown / No / Yes / Explain:
Medication Allergies?(list type) / Unknown / No / Yes / Explain:
Has the child had any of the following problems/experiences? (Check all that apply)
Asthma / Heart Problems / Surgery of any kind? / Explain:
Broken Bones / High or Low Blood Pressure / Thyroid Problem
Convulsion or Seizure / Immune System Problems / Tuberculosis (TB)
Diabetes / Liver Problems or Hepatitis / Urinary Tract or Kidney Problem
Exposure to Toxic Lead Levels / Motor or Movement Problems / Weight Gain or Loss / Explain:
Head Injury / Pregnancy / Speech of Language Problems / Explain:
Hearing Problems / Serious Rash or Other Skin Problem / Other:
Vision Problems / Sexually Transmitted Disease (STD)
CHILD, YOUTH, AND FAMILY STRENGTHS/ASSETS: / Consider Assets, Strengths, Challenges & Needs in the following areas:

Motivation/Insight

Social/Interpersonal

Family

Psychological

Special Talents

Emotional

CHALLENGES AND NEEDS: /

Abilities/Interests

Community Support

Educational

Economic

Vocational

Ability to Access Care

Cultural/Spiritual

Needs outside system

Safety

Medical/Health

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / CLIENT MRN:
MENTAL STATUS EXAMINATION (choose at least one descriptor) Note Cultural & Age explanation for descriptors when applicable:
APPEARANCE / Normal for culture and agedisheveled meticulous poor hygiene
eccentricseductiveinappropriateolder/younger than stated age / Comments:
ATTITUDE / engagingcooperativeuncooperative angry/hostile guarded
provocative sarcastic irritable apatheticshy/timid
silly/naivemanipulativedependentdemandingimpulsive
callousevasivesensitivetearfuloverly dramatic / Comments:
BEHAVIOR / Eating level: Above Normal Normal Below Normal
Energy level:Above Normal Normal Below Normal
Sleeping level:Above Normal Normal Below Normal
nightmares / Comments:
MOTOR ACTIVITY / calm/normallethargic panickyrestless, pacingrepetitive
tics tremorsposturing hyper-activeunusual gait
Eye contact:direct/goodstaringevasivepoor / Comments:
SENSORIUM / alert cloudedconfuseddisorientedstuporous
Orientation:personplaceday/date/yearsituation
INTELLIGENCE (by impression):averageabove average below average / Comments:
MOOD / euthymic (normal range)depressed (extremely sad, despondent)
sadelevated (more cheerful than normal)
irritableeuphoric (exaggerated feeling of well being)
anxious / Comments:
AFFECT / broad (within normal limits)restrictedblunted (severely reduced intensity)
flat (lack of affective expression)labile (rapid shifts in mood, unstable)
mood incongruent / Comments:
PERCEPTION / Within Normal Limits
Hallucinations:visualauditoryother
Other Perceptual Distortions:derealizationdepersonalizationdissociation
distortion of body image / Comments:
THOUGHT FORM/PROCESS / logical lineartangential circumstantial loose
scattered blocked fragmentedflight of ideas perseverative
racing thoughts / Comments:
THOUGHT CONTENT / Within Normal Limits
Delusions:grandiose paranoidsomatic jealous
erotomanic thought broadcastingother
Other Thought Distortions:obsessionscompulsionshypervigilance
suspiciousnessphobiasmagical thinking / ideas of reference
religiosityguiltsexual preoccupation / Comments:
SPEECH / Within Normal Limits incoherent haltingmute
loudsoft rapid pressured slurred
stammer monotonemonosyllabicramblingecholalia
word salad clangingimpoverishedexcessive profanity / Comments:
MEMORY / Remote (history, life events)AdequateFairPoor
Recent (past 24 hours)AdequateFairPoor
Immediate (past 5-10 minutes)AdequateFairPoor / Comments:
CONCENTRATION / attentive distractedunable to concentrate / Comments:
JUDGMENT / Age-appropriate Fair Poor / Comments:
INSIGHT / Age-appropriate self-awareness (Understanding of own challenges and motivation)
Blames others or external factors for problems Denies illness / disability / Comments:
ABSTRACT THINKING / Age-appropriate Significant limitations Very concrete / Comments:
Summary Comments:

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / MRN:
LPHA DIAGNOSIS SOURCE: , Lic/Reg: /

DATE:

ICD 9 CODE:(Principle)
Axis I / (Primary)
Axis I / (Secondary)
Axis II / (Primary) / Axis II / (Secondary)
Axis III

Axis IV

/ 1 Primary Support / Comments:
2 Social Environment / Comments:
3Education / Comments:
4 Occupational / Comments:
5 Housing / Comments:
6 Economic / Comments:
7 Access to Healthcare / Comments:
8 Legal System / Comments:
9 Other / Comments:
0 (None Evident) / Comments:

Axis V

/ Current GAF: Past Year(Optional) GAF: / Comments:
CLINICAL FORMULATIONUse specific behavioral descriptors to address additional clinical information that impacts treatment. (e.g., progression of symptoms, test results/lab values, pertinent history, concomitant issues, factors impeding progress, effectiveness of current strategies.)
______
______
______
______
______
SUMMARY / ADDITIONAL COMMENTS /CONTINUATION FROM OTHER SECTIONS (Include immediate plans for risk indicators and safety plan):
For additional space, check here and attach Additional Page(s)

YLO Child Initial Assessment 12/17/07CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328SEND COPY to County/MHP of Jurisdiction Page 1 of 10

CLIENT NAME: / MRN:

TENTATIVE DISCHARGE PLAN:

Coordination of Care (mark all that apply, list by number below):
1 - Additional Outpatient MH Provider
2 - Day Treatment/Day Rehab
3 - Wraparound
4 – TBS / 5 - Transition Age Youth Services
6 - 0-5 Program
7 – Child Case Mgmt.
8 - Alta Regional Center / 9 - Residential Services
10 - Psychological Testing
11 - Psychiatric Services
12 - Drug & Alcohol Services / 13 - Foster Family
14 - Child Welfare/CPS
15 - Probation Officer
16 - Social Worker / 17 - Physician/Pediatrician
18 - Other healthcare provider
19 - Non-custodial caregiver
20 - Other
# / Name / Agency/Contact Information / Phone Number
Teacher’s Name / School / Phone / Active IEP? / YES
NO
Include meeting date(s) and specific roles and outcomes from Coordination Meeting (If Applicable): / Not Applicable

Notice of Privacy Practices Offered to Client/Caregiver? YesNo

No

SIGNATURES:.
Provider: / Agency/Title: / Date:
LPHA Co-signature
(if required): / Agency/Title: / Date: