Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Assessment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Clinical ID # Client Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age* Sex* Male Female Name of Person Completing Form* First Last Phone*Email Enter Email Confirm Email Legal Guardian(s)*First NameLast NameEmail Address Are there any custody or visitation agreements?* Yes No Please explain:*Referral SourceReferral Source Community Provider County Family/Friend Law Enforcement Medical Facility School/College Community ProvidersCommunity ProviderAdult/Teen ChallengeAssociates in Psychiatry and PsychologyAttorneyBlue StemChemical Dependency FacilityCourtEAPEmployerEmpowerFamily Service RochesterGroup HomeIRTSNAMIOther CourtOther ProfessionalPhysicianPrairie CarePsychiatristPsychologistRecovery is HappeningVocational Rehab/Employment ServicesCountyCountyBlue Earth CountyDodge CountyFillmore CountyGoodhue CountyHouston CountyMower CountyOlmsted CountyOlmsted County Social ServicesOther County AgencyParole OfficerRice CountySocial ServicesSocial WorkerSteele CountyWabasha CountyWaseca CountyWinona CountyFamily/FriendFamily/FriendFamily/RelativeFriendLaw EnforcementLaw EnforcementBlue Earth County Sheriffs DepartmentDodge County Sheriffs DepartmentFillmore County Sheriffs DepartmentGoodhue County Sheriffs DepartmentHouston County Sheriffs DepartmentLaw Enforcement AgencyMN Department of CorrectionsMower County Sheriffs DepartmentOlmsted County Sheriffs DepartmentRice County Sheriffs DepartmentRochester Police DepartmentSteele County Sheriffs DepartmentWabasha County Sheriffs DepartmentWaseca County Sheriffs DepartmentWinona County Sheriffs DepartmentMedical FacilityMedical FacilityAustin Medical CenterMayo ClinicMayo Clinic Health SystemMental Health AgencyNursing HomeOlmsted Medical CenterRapid Access ClinicSt. Mary's Hospital/Generose/MayoVeteran's HospitalVeteran's ServicesSchool/CollegeSchool/CollegeALCALC - APEXKingsland School DistrictOther School/CollegePine Island ElementaryPine Island High SchoolPine Island Middle SchoolRochester SchoolsAssessment OverviewPresenting Problem(s)/Reason for Assessment*Please provide examples of behaviors that you are concerned about.When did the problems begin?*What have you already done to help with the problems?*Are there, or have there been, other professionals involved in the client's care?* Yes No Select all that apply:*Social WorkerSkills WorkerSchool Social WorkerPsychologist/TherapistSchool PsychologistYouth Behavioral HealthIn-Home TherapistPediatricianProbation OfficerMedical SpecialistChild ProtectionSchool CounselorFoster ParentsMentorOther ProfessionalsPlease list any other professionals:*Please describe what services were provided or offered:*Please select the symptom(s) the client is currently displaying:*(select all that apply)Aches/painsAnxious/nervousAshamedBlames othersBody image concernsCan't enjoy myselfChoking feelingCry easily/oftenDepressed/sadDestroys property/firesDifficulty breathingDistressing memoriesDisturbing thoughtsDizzinessEating/appetite concernsElevated moodExcessive worryFeel inferiorFeel unworthyFeeling paranoid/suspiciousForgetfulFrequent mood swingsFrustrationGuilt feelingsHeadachesHear voicesHeart racingHeavy feelingHoardingHopelessnessHyperactivityImpulsiveIrritable/angryLack of motivationLies/stealsLonelinessLose temperLow energy/tiredLow self-esteemMotor or verbal ticsNightmaresNumbness/tinglingPhysical aggression/cruelty to animalsPoor concentrationPoor memoryRacing thoughtsRepetitive actionsRestless/fidgetySee images or objectsSelf harming behaviors/urgesSexual issues/concernsShakingSleep problemsSocial discomfortTense feelingsThoughts of wanting to dieThoughts of wanting to hurt othersWound upWhat areas have been impaired by the symptoms listed above:*(select all that apply)Coping skillsDaily living skillsEconomic/financial impairmentEducational/school functionHealthHousing/shelterLegal difficultiesMarital/family conflict or dysfunctionOccupational functioningSelf protection/personal safetySexual functioningSocializationOtherPlease list any other areas that have been impaired:*Chemical Use HistoryHas the client ever used tobacco?* Yes No Please describe the tobacco use:*Does the client drink alcohol or use drugs?* Yes No What was the age of first use?* What is typically used and how much?*Has anyone been concerned by the client's chemical use?* Yes No Please explain.*Have there been any negative consequences or treatment involvement?* Yes No Please explain.*Has gambling ever been a concern and/or caused problems?* Yes No Please explain.*Please describe the family history of addictions or chemical dependency:*Medical HistoryWho is the client's healthcare provider? When was the client's last physical exam? Describe any current medical problems or physical symptoms the client is having:List any medications the client is taking:Name of MedicationDosage (if known)Reason for use (if known) Please list any important medical information (illnesses, injuries, surgeries, drug side effects, etc.):Does the client have any allergies?* Yes No Please list all known allergies:*Has the client ever been hit in the head, or suffered head or brain trauma or injury?* Yes No Please explain:Mental Health HistoryHas the client had thoughts or actions of suicide or self-harm? Or harming another person?* Yes No Please explain:List the client's strengths and vulnerabilities:*List the client's triggers and warning signs for relapse:*Please list previous mental health services (include therapy, psychiatry, hospitalizations, commitments, county services, etc):Date of serviceWhere the client was seen/treatedFocus of treatment List current and previous medications that have been prescribed for mental health or psychiatric reasons:MedicationDosage (if known)Reason for use (if known) Social/Relationship HistoryHas the client begun to date?* Yes No How old was the client?* Have these relationships been healthy, or has there been any maltreatment and/or abuse?*Is the client sexually active?* Yes No Does the client have children?* Yes No Please provide name(s) and age(s)*NameAge Describe the client's interests:(time with friends, hobbies, sports, etc.)Please list any spiritual or cultural considerations you would like us to be aware of:What are the client's coping skills?Education/Work HistoryWhat school does the client attend?* Current grade:* Describe the client's school experience:*(Please be specific and include how many schools the client has attended, academic progress, social involvement, extra-curricular involvement, getting along with teachers and peers, etc.)Have there been any difficulties in school?*(Please include in/out of school suspensions, expulsions, truancy, or other academic issues)Does the client have an Individualized Education Plan (IEP)?* Yes No Please describe the special needs and services provided.*Please bring a copy of the plan to the client's appointment.Is there a family history of family academic problems or concerns?* Yes No Please describe:*Legal HistoryDoes the client have any past or current legal problems?* Yes No For what? Please provide name of Probation Officer, if applicable.*Has the client been ordered by court/probation for assessment, to attend therapy or treatment?* Yes No Family HistoryWhere was the client born and where has the client lived since?*What has growing up been like for the client?*Has the client been exposed to violence in the family or elsewhere (verbal, emotional, sexual, physical)?* Yes No Please explain:*Has the client been abused, neglected, or maltreated by anyone?* Yes No Please explain what happened:*Please complete the following information about significant caregivers the client has lived with: (parents, step, grand, or foster-parents, etc.)*NameRelationshipAgeOccupationAlive? (Yes/No) Are the client's parents divorced?* Yes No How old was the client at the time of the divorce?* Please complete the following information about sibling, step-siblings, or half-siblings:*NameRelationshipAgeOccupationAlive? (Yes/No) Who currently lives in the home with the client?*NameRelationship Please describe the current relationships with the parents / caregivers / siblings:*Have any family members been treated for or diagnosed with a mental illness?* Yes No Please explain:*Has the client known anyone that committed suicide?* Yes No Please explain:*Are you aware of any developmental problems or concerns from pregnancy / birth / childhood / adolescence? Was there the potential for maternal chemical use during pregnancy?*At about what age did the client complete the following?(mark NA if not yet obtained)Walk alone:* Complete toilet training:* Speak in sentences:* Sleep through the night:* Discontinue bed wetting:* Other:* Have there been any concerns about the client meeting these developmental milestones or any others?*Coordination of CarePlease list any other service providers that are assisting the client:Please give any additional information that may be important or beneficial in treating the client:What do you enjoy most about the client? Or as the client, what makes you a special or unique person?*CommentsThis field is for validation purposes and should be left unchanged.
