foster_care_project_standardized_documentation_assessment.doc - Provider       Coordinator       Out of Area COUNTY Mental Health

Foster_care_project_standardized_documentation_assessment.doc

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Provider: Out of Area COUNTY______________________ 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/CPS School Physician Parent / Caregiver Therapist Probatio n Self Phone : Contact : LEGAL STATUS AND SPECIAL POPULATIONS: Voluntary Dep. of Court (300 W&I) Alta Regional Ctr . 26.5 / AB3632 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 - BLUE Child ACP Data Entry 01/15/04 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 1 of 11
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FUNCTIONAL IMPAIRMENT PRESENTING PROBLEMS / TARGETED SYMPTOMS / REASONS FOR SERVICE: Functioning 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 Non e Mil d Moder ate Mark ed Extrem e (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 BLUE Child ACP Data Entry 01/15/04 CONFIDENTIAL PATIENT/CLIENT INFORMATION: See W&I Code 5328 SEND COPY to County/MHP of Jurisdiction Page 2 of 11
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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.
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