Fillable ClinicalAssessment 1. IDENTIFYINGINFORMATION InsuredsSSNorID: ProviderPhone: Lic.# YesNo CountyPCPMemberHolman

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ClinicalAssessment 1. IDENTIFYINGINFORMATION InsuredsSSNorID: ProviderPhone: Lic.# YesNo CountyPCPMemberHolman

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ClinicalAssessment
P.O.Box8011
CanogaPark,CA91309 Office:800‐321‐2843 Fax:818‐704‐4252
LastUpdated:06/03/2020www.holmangroup.comPage1of2
1. IDENTIFYINGINFORMATION
ClientName: DateofFirstAppointment:
Ifdateseenwasmorethan5‐daysfromdateassignedtoProvider,pleaseexplain:
ClientAddress: ClientPhone:
ClientDateofBirth: ClientGender: ProviderName:
Insured’sSSNorID: ProviderPhone: Lic.#
Insured’sEmployer: IsPatientonDisability?:
☐Yes☐No
Clientwasreferredby:
☐County☐PCP☐Member☐Holman
2. PRESENTINGPROBLEM(includingprecipitatingevents/currentstressors/relevanthistory)
3. DESIREDOUTCOMEOFTREATMENT
4. CURRENTRISKFACTORS
A. Suicidality:
☐None CurrentIdeation:☐Yes☐No Intent:☐Yes☐No
Means:☐Yes☐No PastAttempts:☐Yes☐No CurrentSafetyPlan:☐Yes☐No
B. Homicidality:
☐None CurrentIdeation:☐Yes☐No Intent:☐Yes☐No
Plan:☐Yes☐No
C. Current/PastPhysical/SexualAbuse,orChild/ElderNeglect:☐Yes☐No
If“yes”,patientis:
☐Perpetrator ☐Victim Hastheabusebeenlegallyreported?☐Yes☐No
If“yes”toanyoftheabove,pleaseexplain:
D. CurrentDrugandAlcoholUse:
☐None ☐Use ☐Abuse ☐Dependence
Substance Quantity Frequency LastUsed DurationofUse
#ofAttemptsat
Sobriety
TypeofCDTxmt



5. PREVIOUSMEDICAL,ANDPSYCHIATRICTREATMENT(Pleasecheckallthatapply)
☐InpatientPsychiatric(date): ☐OutpatientPsychiatric(date): ☐Self‐HelpSupportGroup:
☐PsychotropicMedicationMana gement ☐SignificantMedical(type&date) ☐Other:
DateofLastPhysicalExam: NameofPrimaryCarePhysician:
6. CURRENTMEDICATIONS
NameofMedication CurrentDosage/Frequency StartDate



Prescribingphysician(indicateifPrimaryCareProviderofPsychiatrist):
7. RELEVANTSOCIALHISTORY
Ethnic/ReligiousID: Docultural,ethnicorreligiousfactorsaffecttreatment?
☐Yes☐No
If“yes”,pleaseexplain:
ClientName:_____________________________________
ClinicalAssessment
CanogaPark,CA91309 Office:800‐321‐2843 Fax:818‐704‐4252
P.O.Box8011
LastUpdated:06/23/2020 www.holmangroup.com Page2of2
8. MENTALSTATUSEXAM(Pleasecheckappropriateboxforeachcategory)
Affect:
☐Appropriate ☐Labile ☐Expansive ☐Constricted ☐Blunted
Mood:
☐Normal ☐Depressed ☐Anxious ☐Euphoric
Appearance:
☐Well‐groomed ☐Disheveled ☐Bizarre ☐Inappropriate
MotorActivity:
☐Calm ☐Hyperactive ☐Agitated ☐Tremors/Tics ☐MuscleSpasms
ThoughtProcess:
☐Intact ☐Tangential ☐Circumstantial ☐FlightofIdeas ☐LooseAssociations ☐Confused
Hallucinations:
☐None ☐Auditory ☐Visual ☐Olfactory ☐Command
Delusions:
☐None ☐Persecutory ☐Grandiose
Memory:
☐Intact ☐Impaired ☐Immediate ☐Recent ☐Remote
Judgment:
☐Intact ☐Impaired ☐Mild ☐Moderate ☐Severe
Orientation:
☐Intact ☐Impaired ☐Date ☐Place ☐Time ☐Situation
Speech:
☐Normal ☐Slowed ☐Pressured ☐Slurred ☐Stuttering
9. DIAGNOSIS
_____
___.___________________________________ ________.___________________________________
MedicalConditions:
10. PATIENT’SCHALLENGES
11. STRENGTHS
12. ASSESSMENTANDCONCLUSION
13. TREATMENTGOALS
14. REQUESTFORTREATMENTAUTHORIZATION
☐ProblemResolved–Nofurthersessionsneeded.
Numberofsessionsused:
Thisisarequestfor:
☐IndividualTx ☐GroupTx ☐Other:(Explain)
MedicationMgt.:
☐EM99213/EM99214 ☐EM+90833(20‐30min) ☐EM+90836(45‐50min) ☐Other:
TreatmentFrequency: TimesPerWeek: Month: Other:
Torequestreferralscoveredunderthepatient’sHolmanmentalhealthbenefits,pleasecall(800)321‐2843.
☐ Icertifythattheaboveistrueandcorrect.Thetreatmentplanhasbeenreviewedandagreeduponbythepatient.
ProviderSignature: Date:
FORHOLMANUSEONLY
#ofSessions/Service/Frequency
#ofSessions/Service/Frequency
DateSpan:
Note:
Signature: Date:
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ClinicalAssessment 1. IDENTIFYINGINFORMATION InsuredsSSNorID: ProviderPhone: Lic. YesNo CountyPCPMemberHolman

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Completed 19 January 2021

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