source: Beacon/ Foothills Behavioral Health/ Rhonda Borders. Meets Colorado Medicaid documentation standard, which is based on Federal req,
Date of Request
Date of Assessment
Persons Present
Source of Referral
Transportation asst/referral needed?
Yes
No
PRESENTING PROBLEM. What does Client report as the problem in emotional and behavioral terms.
PRECIPITATING FACTORS OR EVENTS. Why tx now?
CURRENT SYMPTOMS AND IMPACT ON FUNCTIONING include onset, progression, frequency, intensity and impact of emotional/behavioral symptoms, impact on roles, last time w no symptoms, what's been tried, what worked.
Risk of Suicide/Homicide/Grave Disability/Elopement/Other/None. Write Safety Plan if needed.
General level of functioning: sleep, appetite, exercise, ADLs (Activities of Daily Living)
CULTURAL FACTORS THAT MAY IMPACT TREATMENT (may include age, values/beliefs, preferred language, communication needs, gender, sexual orientation, relational roles, among others. State what impact they may have.)
Psychosocial Hx: supports and stressors; Socioeconomic, Family, Legal, Social, Abuse, neglect, domestic violence, school adjustment
Education/ Employment/ Vocational/ Military Service/ Avocations:
CLIENT STRENGTHS: (include personal characteristics, attitudes/beliefs, resources, achievements, and abilities that will help client achieve goals of treatment)
Previous treatment history and response, most recent treatment, past treatment failures, Relapse/recidivism, motivation for treatment o Indications of compliance with treatment recommendations
For members 12 and older, documentation includes past and present use of cigarettes and alcohol, as well as illicit, prescribed, and over-the-counter drugs. Include: Type, Amount, Withdrawal symptoms, Vital signs, Date(s) of initial use and last use, Date(s) of periods of sobriety
FAMILY HISTORY OF MH, MEDICAL OR SUBSTANCE PROBLEMS:
children and adolescents, past medical and psychiatric history includes prenatal and perinatal events (when available), along with a developmental history (physical, psychological, social, intellectual and academic).
FAMILY/GUARDIAN SOCIAL/ENVIRONMENTAL NEEDS OR STRENGTHS that may impact child’s condition or progress.
MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES/ORGANIC CONDITIONS that may impact presentation or functioning
CONCERNS OF AGING for Clients 60 or older: (include loss of hearing, vision, mobility, physical functioning, other factors of aging)
MEDICAL AND DENTAL CONDITIONS that may impact presentation or functioning: (include allergies, date of last physical)
medications have been prescribed, the dosages of each and the dates of initial prescription or refills. Type(s), Dosage(s), Date(s), Duration, Response, Provider(s)
Medication allergies, adverse reactions and relevant medical conditions
Clinical Formulation: identify/prioritize needs, concerns, symptoms, deficits, behaviors; support using “as evidenced by”, “Needs to learn, needs to manage, needs to develop…” Explain diagnosis as summary of symptoms/behaviors and note DSM criteria What will be addressed at this level of care initially Discuss strengths, cultural factors, and supports that will support treatment, including client/family willingness and ability to participate Justify medical necessity (medical necessity = current problem in functioning, and signs and symptoms that can be helped by named services)
DSM diagnosis (consistent with the presenting problems, history, mental status examination, and/or other assessment data.)
