rev2Mental_Heath_Forms_6

rev2Mental_Heath_Forms_6 - Client Name Date o 09...

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San Jose State University Nurse Managed Centers Problem List /Ratings Worksheet/Interventions Client Name Client Number Center Date Nurse Mental Health Form o 09 INTERPERSONAL RELATIONSHIP o Adequate o Not Assessed o Health Promotion o Potential o Impairment o Ind. o Family Rating o Cat.   Target #  Client Specific Information Data/Risk Factors o 01. Difficulty establishing/maintaining          1        2        3        4        5 I o   relationships o 02. Minimal shared activities K      o        o        o        o        o II o    o 03. Incongruent values/goals/expectations/schedules o 04. Inadequate interpersonal B      o        o        o        o        o III o communication skills o 05. Prolonged unrelieved tension S      o        o        o        o        o IV o  o o 06. Inappropriate suspicion/manipulation/compulsion/control 07.Physically/emotionally abusive to partner 08 Difficulty problem solving without conflict 09. Other o 11. GRIEF o Adequate o Not Assessed o Health Promotion o Potential o Impairment o Ind. o Family Rating o Cat. Target # Client Specific Information Data/Risk Factors o 01. Fail to recognize stages of grief/process of healing 1 2 3 4 5 I o o 02. Difficulty coping with grief responses K o o o o o II o o 03. Difficulties expressing grief responses B o o o o o III o o 04. Conflicting stages of grief process among family./individuals S o o o o o IV o o 05. Other o 12. MENTAL HEALTH o Adequate o Not Assessed
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rev2Mental_Heath_Forms_6 - Client Name Date o 09...

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