ADULT BEHAVIORAL HEALTH ASSESSMENT









    I. CHIEF COMPLAINANT

    (Major symptoms, difficulties, and/or Issues as they relate to behavioral health –in client/members’s/caretaker’s own words/quoted.)























    THe Mental Health Continuum










    II. PRESENTING PROBLEM/RELEVANT HISTORY

    (Including client/member/caretaker/guardian reason for seeking services, precipitating factors, symptoms, behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and expectations.)






    III. PAST PSYCHIATRIC/PLACEMENT HISTORY

    (First onset of illness, past diagnostic and treatment history, medications, hospitalizations)






    IV. SUBSTANCE USE HISTORY

    (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.)


    No. Patient has no substance history at all.
















    V. PRIMARY CARE PHYSICIAN



    Locus Dimension III: Co-Morbidity:

    Medical, Addictive and Psychiatric Co-Morbidity






    (Diagnosis, Hospitalizations, Surgery, labs values, status of conditions, etc.)






















    VII. LEGAL STATUS



    VIII. FAMILY HISTORY

    (relationship status with relatives, family involvement in treatment, and living status of significant relatives)








    X. LIVING SITUATION

    (Current status and functioning)











    Calocus Dimension IV: Recovery Environment

    A. Level of Stress






    B. Level of Support






    XI. EDUCATIONAL/EMPLOYMENT STATUS

    Locus Dimension II: Functional Status









    XII. SOCIAL HISTORY AND COMMUNITY INTEGRATION

    Current status and functioning

    (Involvement in the community, social supports and activities, social barriers)



    XIII. MENTAL STATUS EXAMINATIONEGRATION


















    XIV. RISK ASSESSMENT

    Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use, criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc.






    Locus Dimension I: Risk of Harm






    Locus Dimension VI: Engagement