SOC CAR CHEAT SHEET – HARD COPY
Domain 1
MILD MODERATE SEVERE
MOOD LABIALITY AEB
laughs out of context cries out of context
Displays various emotions that do not fit with conversation & subject matter
MILD MODERATE SEVERE
DEPRESSION AEB
sleeps excessively Fatigued Lacks motivation
Lacks desire irritable Sits & does nothing during the day crying spells Lays on the sofa Remains in bed
AFFECTS LEVEL OF FUNCTIONING
Fights with significant partner or family members
Lack of interest places primary relationship at risk Avoids social contact
Neglects personal hygiene Neglects home chores
Neglects homework or other responsibilities Neglects pets
other ______
______
Direct quote from consumer about the depression that they experience______
______
______
MILD MODERATE SEVERE
EUPHORIA AEB
Excessive energy little to no sleep believes can accomplish anything
Extreme feelings of high other ______
______
Direct quote from consumer about the highs ______
______
AFFECTS LEVEL OF FUNCTIONING
Crashes after several days of emotional highs enters into severe depression
Lack of sleep results in psychosis, ie: hallucinations, delusional thought
Develops poor focus disoriented thought primary relationship jeopardized
Social contacts withdraw from consumer due to extreme emotional highs
Develops compulsions ie cleaning, rituals, etc. other ______
______
COPING SKILLS AEB
Uses drugs & alcohol sleeps it away withdraws shuts down
Eats excessively watches TV spends money
Uses positive skills ie journaling, talking to a friend, exercise, walking, etc
MILD MODERATE SEVERE
ANGER AEB
yells, screams throws things hits or fights holds it in
shuts down shows anger by deliberately destroying other person’s things
feelings are intense but no outward display of emotion
withdraws into a private place chooses to hurt themselves when angry
tends to rant & rave at others other______
______
AFFECTS LEVEL OF FUNCTIONING AEB
destroys relationships gets fired from jobs causes physical problems, ie ulcers, high blood pressure, etc Asked to leave the environment whether public or private setting intimidating behaviors aggression legal problems
expelled from school suspended from school detention
other ______
______
MILD MODERATE SEVERE
SLEEP AEB
sleeps long hours reversed days & nights averages ___ hours per night
sleeps few hours tosses & turns gets up throughout the night
bad, disturbing dreams wakes in pain other ______
______
AFFECTS LEVEL OF FUNCTIONING AEB
can’t participate in community doesn’t socialize no family life
APPETITE AEB
eats excessively eats when stressed loses appetite when under emotional stress eats one meal a day becomes ill when they eat
AFFECTS LEVEL OF FUNCTIONING AEB:
shops for quick foods doesn’t make dinner resorts to protein bars, etc
developed an eating disorder
MILD MODERATE SEVERE
SUICIDAL AEB
frequent thoughts plan desire to be dead little thought or care for their life other______
______
Direct quote from consumer about suicidal thoughts ______
______
HOMICIDAL AEB
voices desire to hurt someone Mentions a specific name of someone that they want to hurt or kill (this must be immediately reported to the individual & the police that a threat has been made according to the Tarisoff Act)
MILD MODERATE SEVERE
ANXIETY AEB
shaking nervous feeling sweating heart palpitations
wobbly knees nauseousdiarrhea vomiting
fidgety other ______
______
AFFECTS LEVEL OF FUNCTIONING AEB
remains in the home agoraphobia developed fears & phobias
rituals or development of compulsions inability to conduct business affairs whether in person or on the phone dreads going to school
stammers or stutters when trying to speak puts off going out, but will go out in public eventually communication limited to phone or computer
shops by delivery only other______
direct quote from consumer about anxiety: ______
______
Score:______
DOMAIN 2
MEMORY AEB
Frequently misplaces things forgets to do assignments
forgets numbers & names unable to recall material just read
JUDGMENT AEB
easily taken advantage of is manipulated for money or cigarettes
takes strangers into home gives money away
unprotected sex other______
BELIEF SYSTEM AEB
lacks core values demonstrates poor sense of right or wrong
illegal behavior is okay if it meets their needs
its okay to do as long as you don’t get caught
frequent sex partners other______
COGNITIVE THOUGHT AEB
disoriented confusion muddled racing thoughts
easily distracted in thought jumps from subject to subject
constantly interrupting paranoia
other ______
OBSESSIONS AEB
worries excessively obsesses over a relationship sex addict
pornography shopping other ______
______
LEARNING DISABILITY AEB
reading comprehension math difficulties processing information
other ______
CONCENTRATION AEB
unable to complete a task can’t stay focused for more than ____ minutes
unable to focus to read unable to focus to fill out paperwork
unable to follow simple instructions mind frequently wanders
loses track on conversation mind may go blank frequently
unable to complete school assignments does not listen to parents/teachers
other______
DELUSIONS/HALLUCINATIONS AEB
auditory voices conversation noise background noise
screaming specific things said by voices ______
______
______
music other ______
visual shadows people corner of the eye animated ie fish swimming in the sidewalk other______
delusional thought (describe delusion)______
______
______
direct quote from consumer______
______
______
IMPULSE CONTROL AEB
overspends multiple sex partners leaves town unexpectedly
disappears without telling anyone spontaneous emotional outbursts
speaking out inappropriately spontaneous outbursts in the classroom
unable to keep hands to themselves
other______
Score:_____
INTERPERSONAL
abrasive behavior aggressive tone frequently confrontive
lacks empathy self-centered egotistical
too quiet annoying conflicts
poor self-esteem no friends few friends
acquaintances, but no close friends distrusts or paranoia
doesn’t like people other ______
direct quote______
Score:______
ROLE PERFORMANCE
employed volunteer student home worker
parent personal responsibilities spouse
other______
See level of functioning for scoring
FAMILY
lives alone roommate biological family
boyfriend/girlfriend children
frequent arguments estranged physical fights domestics
alcohol problems drug problems over controlling
other______
direct quote______
______
Score:______
MEDICAL PROBLEMS
______
______
______
Medicinedosagefrequencypurpose
Score______
DRUG/ALCOHOL USE
Drug/alcoholamountfrequency1st usedlast used
AFFECTS FUNCTIONING AEB
destroys primary relationship frequent firing frequently late
misses appointments runs out of money
other______
TREATMENT ______
______
Score_____
AFFECTS LEVEL OF FUNCTIONING AEB
(support for alcohol/drug use, self-care, social relationships, legal, & role performance)
Can’t hold a job Misses appointments won’t go into public
no medical no dental no transportation
lost drivers license illegal involvement contact with the law
probation lost/in danger of losing primary relationship
no friends no social support withdraws
isolates disrupted family life unstable relationships
won’t socialize homeless no income
pays bills late unable to pay bills (overspends)
no shelter inadequate shelter no food or way to maintain food
no personal items poor hygiene poor health due to lack of care
frequently suicidal frequently accesses ER or EOC worker due to emotional problems frequent suspension frequently sent to the office
detention
unable to care for self frequently gets off of meds
can’t maintain personal business can’t budget money
other______
______
Self-care score:______
Legal score:______
Role performance score______
REASON FOR LEGAL ISSUES: (if there are legal problems pending it must be noted in the summary, ie probation for drug charge) ______
______
______
______
PROGRESS MADE IN LAST PERIOD(use MHSP for progress on goals. This must be a summary of the progress written on the service plan itself under each set of objectives.) ____________
______
______
______
SERVICES TO BE USED TO ADDRESS GOALS IN COMING SERVICE PERIOD:______
______
______
______
______
BARRIERS TO RECOVERY:______
______
______
STRENGTHS TO RECOVERY: ______
______
______
STATEMENT ABOUT TREATMENT FOR DRUG/ALCOHOL USE: (must clearly state that consumer does not want treatment to address drugs or alcohol or the referral made to assist consumer)
Letter of collaboration for joint services with another facility billing soonercare.
PROGNOSIS:______
Once this is finished, you should have all the information needed to type up your tx summary. For DMH you will simply pull out the information that applies and add flow words and write out a narrative. For APS Care Connection, start the summary with a broad statement of symptoms that are experienced and then state see Current section. In the current section, you will place the symptoms and how those symptoms are affecting their daily functioning. Be thorough, since this is the place that will support the CAR scores. Your treatment summary will then be completed by filling in the remainder of questions, ie legal, barriers, prognosis, alcohol use, and anything that you feel is relevant to the treatment.
For use on MHSP
THINGS CONSUMER WANTS TO WORK ON: (must be seen in the treatment summary or the CAR)
______
______
______
GOALS: (In consumer’s own words)______
______
______
______
______
Forms/Clinical/Compliance Checklist/SOC-CARCheatHC.doc rev 10/04/20071