Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Assessment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Clinical ID # Client Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current 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: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 up(select all that apply)What 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 HistoryPlease describe any family history of addiction 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 HistoryDescribe 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 or daycare does the client attend? Current grade (if applicable): Describe the client's school and/or daycare 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 and/or daycare?(Please include in/out of school suspensions, expulsions, truancy, or other academic issues)Does the client have an Individualized Education Plan? 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:Family HistoryWhere was the client born and where has he/she 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?Adverse Childhood Experience (ACE) QuestionnairePlease answer yes or no to all of the following questions for an accurate score.Did a parent or other adult in the household often swear at the client, insult the client, put the client down, or humiliate the client? Or act in a way that made the client afraid that they might be physically hurt? Yes No Did a parent or other adult in the household often push, grab, slap, or throw something at the client? Or ever hit the client so hard that the client had marks or was injured? Yes No Did an adult or person at least 5 years older than the client ever touch or fondle the client, or have the client touch their body in a sexual way? Or try to or actually have oral, anal, or vaginal sex with the client? Yes No Did the client often feel that no one in their family loved them or thought they were important or special? Or that the client's family didn't look out for each other, feel close to each other, or support each other? Yes No Did the client often feel that they didn't have enough to eat, had to wear dirty clothes, and had no one to protect them? Or the client's parents were too drunk or high to take care of the client or take the client to the doctor if they needed it? Yes No Were the client's parents ever separated or divorced? Yes No Was the client's mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No Did the client live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No Did a household member go to prison? Yes No This is the client's ACE score:PhoneThis field is for validation purposes and should be left unchanged.
