Fillable MENTAL HEALTH PLAN ASSESSMENT FORM (County of San Bernardino Information Services Dept.)

Fill Online, Printable, Fillable, Blank MENTAL HEALTH PLAN ASSESSMENT FORM (County of San Bernardino Information Services Dept.) Form

Use Fill to complete blank online COUNTY OF SAN BERNARDINO INFORMATION SERVICES DEPT. (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MENTAL HEALTH PLAN ASSESSMENT FORM (County of San Bernardino Information Services Dept.)

On average this form takes 42 minutes to complete

The MENTAL HEALTH PLAN ASSESSMENT FORM (County of San Bernardino Information Services Dept.) form is 6 pages long and contains:

  • 0 signatures
  • 137 check-boxes
  • 105 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of San Bernardino Information Services Dept.

BROWSE COUNTY OF SAN BERNARDINO INFORMATION SERVICES DEPT. (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 1 of 6
Every item must be completed.
Date Provider Phone
Provider Office Address_______________________________________________________________
Client Name _____________________________ D.O.B._____________SSN_________________
Consent to treat given by: ☐ Self ☐ Parent/Guardian ☐ Conservator
Referral
☐ Self ☐ School ☐ Probation ☐ Court ☐ CPS ☐ APS ☐ Parent/Guardian/Conservator ☐
Access Unit
☐ Other
Living Arrangement
☐ Own House ☐ Bio Family ☐ Foster Family ☐ Group Home ☐ SNF ☐ B&C
Ethnicity________________________ Language Preferred for Services______________________
Emergency Contact Relationship Phone
Address______________________________________________________________________________
Presenting Problem (nature and history)
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 2 of 6
Risk Assessment
Current harm to self-risk
☐
N/A
☐
Ideation
☐
Intent
☐
Plan
☐
Means
Describe:
History of:
Current harm to others risk
☐
N/A
☐
Ideation
☐
Intent
☐
Plan
☐
Means:
Describe:
History of:
Assaultive/Combative
☐
No
☐
Yes If yes, describe:
At risk of abuse or victimization
☐
No
☐
Yes Describe:
Have all mandated reporting requirements been met?
☐
Yes, by this Provider
Yes, by :
☐
No (Explain)
Other:
Client Strengths
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 3 of 6
Client Name:
Culture/Diversity: Assess unique aspects of the client, including culture, background, and sexual
orientation, that are important for understanding and engaging the client and for care planning.
Preferred language for receiving our services:
Culture client most identifies with:
Problems client has had because his/her cultural background:
☐
None
Sexual orientation issues:
☐
None
Support/ involvement of family in client’s life:
☐
Desire of client involvement of family or others in treatment:
☐ Desires
Psychiatric History (Medication(s) and dosage (current))
Medication(s) (past):
History of Mental Illness in Family
☐
No
☐
Yes If yes, describe:
Prior Hospitalization(s)
☐
No
☐
Yes If yes, when, where
Prior Outpatient Treatment
☐
No
☐
Yes If yes, when and with whom
:
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 4 of 6
Client Name:
Medical History Health Problems (current)
☐
No
☐
Yes If yes, describe:
Height:
Weight :
(Mandatory if client is a MINOR)
Sleep Disturbance ☐ No ☐ Yes If yes, describe:
Appetite
☐
Too Little
☐
Too Much
Weight gain:
lbs.
Weight Loss:
lbs.
Disability
☐
Developmental
☐
Physical
☐
Cognitive Describe:
Allergies
☐
No
☐
Yes Describe:
Adverse response to medications
☐
No
☐
Yes If yes, describe:
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 5 of 6
Substance Use/ Abuse
No Use
Frequency
Amount
Last Use
Nicotine
☐
Caffeine
☐
Alcohol
☐
Marijuana
☐
Amphetamines
☐
Hallucinogens
☐
Cocaine/Crack
☐
Heroin
☐
Prescription Meds
☐
Other:
☐
Mental Status
Appearance:
☐
Clean
☐
Well-groomed
☐
Dirty
☐
Disheveled
☐
Inappropriate clothing
Orientation:
☐
Person
☐
Place
☐
Time
☐
Situation
☐
Disoriented
Speech:
☐
Organized/Clear
☐
Coherent
☐
Rapid
☐
Slowed
☐
Mumbling
Thought Process:
☐
Organized
☐
Coherent
☐
Tangential
☐
Thought Blocking
☐
Flight of Ideas
☐
Poor Concentration
☐
Obsessive
Thought Content:
☐
Normal
☐
Delusional
☐
Grandiose
☐
Other
Perceptual Process:
☐
Normal
☐
Auditory hallucinations
☐
Visual hallucinations
☐
Other
Insight:
☐
Good
☐
Average
☐
Poor
☐
None
Judgment:
☐
Good
☐
Average
☐
Poor
☐
None
Mood:
☐
Normal
☐
Hopeless
☐
Irritable
☐
Elevated
☐
Labile
☐
Depressed
☐
Anxious
☐
Sad
☐
Manic
Affect:
☐
Appropriate
☐
Inappropriate
☐
Blunted
☐
Flat
☐
Tearful
Memory:
☐
Intact
☐
Immediate Memory Problem
☐
Recent Memory
Problem
☐
Remote Memory
Estimated Intellectual
Functioning:
☐
Average
☐
Below Average
☐
Above Average
Cognitive Deficits:
☐
None
☐
Cognitive Deficits Present
☐
Concentration Deficits Present
MENTAL HEALTH PLAN ASSESSMENT FORM
REV. 3. 2016 Page 6 of 6
Client Name:
Impairments requiring Mental Health Treatment:
Dysfunction Rating
☐
None
☐
Mild
☐
Moderate
☐
Severe
Describe how symptoms impair functioning:
Employment/ Education:
Occupation:
☐
Competitive job market, 35 hours or more per
week
☐
Rehabilitative work, less than 20 hours per
week.
☐
Volunteer Work
☐
Competitive job market, less than 20 hours per
week
☐
School, full time
☐
Retired
☐
Full-time homemaking responsibility
☐
Job training, full time
☐
Resident/Inmate
☐
Rehabilitative work, 35 hours or more per week
☐
Part-time school/job training
☐
Unknown
☐
Not in Labor force
☐
Highest Grade completed__________
Medical Necessity
*
☐
Qualifying mental health diagnosis
☐
Qualifying impairment is an important area of life functioning
☐
Probability of a significant deterioration in an important area of life functioning
☐
(Children only) Probability that child will not progress developmentally as individually appropriate
☐
EPSDT – Qualified
*
☐
Planned interventions will address impairment conditions
*
☐
Client is reasonably expected to benefit and improve with respect to impairments
*
☐
Condition would not be responsive to physical health care-based treatment
*All asterisked items must be present, plus 1 more and must be supported by documentation in record
Other Providers/ Agencies client is involved with:
Signature of Provider Date
Printed Name
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MENTAL HEALTH PLAN ASSESSMENT FORM (County of San Bernardino Information Services Dept.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document