
ASSESSMENT DETAILS | |
Clinician: Place: Program: Date: Time: | |
Precipitants History of current episode & treatment Change in behaviour Signs and symptoms: HallucinationsAbnormal IdeationPreoccupationsSuicidal IdeationAggressiveHomicidal thoughtsAnxiety statesMood disturbanceSleepAppetiteSubstance abuse Other disability IDS/Physical Demographics Major Illnesses Surgical Interventions Current medical health | PRESENTING PROBLEMS (Clients perception of problem) |
COLLATERAL HISTORY | |
MEDICAL HISTORY/CURRENT MEDICATIONS |
PSYCHIATRIC HISTORY / MHA STATUS | |
FAMILY HISTORY (Includes family history of mental illness, quality of relationships, current family issues) | |
GENOGRAM | |
Genogram Key Male Female Unknown Married Defacto Separated Divorce Adoption Death | |
Milestones School Academic performance Social development Friends at school Childhood interests Hobbies Current support network Psychosexual development Significant intimate relationships Cultural Issues Reason for migration Connection with community Recreational interests Capacity for independent living | PERSONAL HISTORY |
Appearance PhysicalDressGrooming Personal hygiene Behaviour GuardedSuspiciousDistractedPsychomotor retardationCompulsionsPanic attacksCatatonic behaviorEye contactMannerismsDegree cooperationRapportGait Speech Rate, volume, toneCoherenceSpontaneityRepetition Thought form Flight of ideasLoosening of associationCircumstantialityConfabulationIncoherencePoverty of thoughtNeologismsPerserverationsEcholaliaClanging | MENTAL STATUS EXAMINATION |
Thought content Overvalued ideasIllogical thinkingIdeas of referenceParanoid ideationThought withdrawalThought insertionDelusionsAnhedoniaHomicidal/suicidal Disorders of perception IllusionsHallucinations Emotional state Cognitive & biologival Judgment Level of insight |
DRUG ALCOHOL SCREENING | |||||||||
Substance | Past Use | Current Use | Quantity | Frequency | Route | Age First Use | Last Used | ||
Depressants | Benzodiazapines Codeine, morph Cannabis Methadone Heroin | ||||||||
Stimulants | Amphetamine (speed, ice) Ecstasy Cocaine | ||||||||
Hallucinogens | LSD Mushrooms Inhalants GHB | ||||||||
Alcohol | Spirits Beer Wine | ||||||||
PREVIOUS WITHDRAWAL ATTEMPTS/REHABILITATION | |||||||||
INTERACTION BETWEEN SUBSTANCES & SYMPTOMS | |||||||||
FUNCTION OF USE What the client thinks are good things about use: Level of concern about use: Client’s perception of effects of use: What client would like to do about use: | |||||||||
MANAGEMENT PLAN |
RISK SCREEN | ||||||||
STATIC BACKGROUND CURRENT (DYNAMIC) | ||||||||
Suicide | Yes | No | Unk | Suicide | Yes | No | Unk | Comments |
Previous Attempts | Expressing ideation | |||||||
Family history | Plan/intent | |||||||
Major psych. Diagnosis | Highly distressed | |||||||
Serious medical condition | Hopeless | |||||||
Separated/divorced | Substance abuse | |||||||
Loss of job/retired/role loss | Recent life event | |||||||
Lack of resources | ||||||||
Self-harm | Yes | No | Unk | Self-harm | Yes | No | Unk | |
History of self-harm | Actual or thoughts | |||||||
Yes | No | Unk | Yes | No | Unk | |||
Aggression | Aggression | |||||||
Previous violence | Expressing intent | |||||||
Previous use of weapons | Access to means | |||||||
Male | Paranoid | |||||||
Criminal history | Command hall. | |||||||
Previous ideation | Anger, agitation | |||||||
Childhood maladjustment | Recent violence | |||||||
Role instability | Substance use | |||||||
History of drugs/alcohol | Reduced control | |||||||
Yes | No | Unk | Yes | No | Unk | |||
Vulnerability | Vulnerability | |||||||
Intellectual disability | Cognitive deficit | |||||||
Previous mental illness | Self-neglect | |||||||
Absconding | Non-compliant | |||||||
Sexual vulnerability | Delusional | |||||||
Predatory behaviours | Intrusive | |||||||
Serious medical condition | Physical illness | |||||||
L | M | H | Poor memory &/ orientation | |||||
Level of Risk | Disinhibition | |||||||
Suicide | Disorganization | |||||||
Self-harm | Preoccupation with hospital | |||||||
Aggression | Intent on leaving | |||||||
Vulnerability | Absconding risk | |||||||
PROTECTIVE FACTORS (factors that reduce the likelihood of negative outcome, e.g. supports) | ||||||||
MANAGEMENT PLAN |

Get expert help for COMPREHENSIVE MENTAL HEALTH and many more. 24X7 help, plag free solution. Order online now!