DPBH

Comprehensive/Psychosocial Assessment
Client: ; Parent/Guardian:
Date: ; Time: ; 15 minutes; Billing Code: 90791 In-Office
DATA/DESCRIPTION:
Identifying Information:

Presenting Problem (include referral source):

Presenting DSM Symptoms:

Social/Family History (place of birth, family of origin, current family/relationship, relevant history):

Trauma/Abuse History:

Psychiatric History (client and family):

Psychotropic Medications (current):

Substance Use/Abuse (include relevant history):

CAGE AID Questionnaire (When thinking about drug use, include illegal drug use and the use of prescription drug use
other than prescribed).
1. Have you ever felt that you ought to cut down on your drinking or drug use? YES NO
2. Have people annoyed you by criticizing your drinking or drug use? YES NO
3. Have you ever felt bad or guilty about your drinking or drug use? YES NO
4. Have you ever had a drink or used drugs first thing in the morning to steady
your nerves or to get rid of a hangover? YES NO
Medical History/Problems (include relevant history):

Legal History/Status (include relevant history):

Current Education/Vocational/Occupational Status (include relevant history):

Military/Veterans Status

Persons Expressed Goals:

Cultural/Ethnic/Spiritual/Religious Beliefs

Strengths/Resources:
ASSESSMENT/MENTAL STATUS:
Suicidal Ideations: None; Plan: N/A; Intent: N/A; Means: N/A
Notes:
Suicide Attempts/History:
Homicidal Ideations: None; Plan: N/A; Intent: N/A; Means: N/A
Notes:
Hallucinations: No; Described as:
Affect: Appropriate
Appearance: Well groomed
Eye Contact: Hesitant
Mood: Depressed and Anxious
Behavior: Agitated
Approach: Calm
Thought Content: No noted thought disorder
Memory: WNL
 DPBH

Orientation: X3
Insight: Fair
Judgment: Good
Speech: WNL;
Language: Appropriate
Other:
Additional Mental Status Comments (If applicable): No access to firearms.
DIAGNOSTIC IMPRESSIONS:
Primary Diagnosis: (include code and description):

Secondary Diagnosis: (Include code and description):

Medical Conditions: (General Medical Conditions as reported by client):

ALLERGIES (including drug allergies):

AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS/STRESSORS:
N/A Primary support group; Specify:
N/A Related to the social environment; Specify:
N/A Educational; Specify:
N/A Occupational; Specify:
N/A Housing; Specify:
N/A Economic; Specify:
N/A Access to health care; Specify:
N/A Legal; Specify:
N/A Other; Specify:
LOCUS: (current)
TOTAL OUTCOME RATING SCALE SCORE:; Above Cut Off
TOTAL SESSION RATING SCALE SCORE: ; Above Cut Off
SMI/Non-SMI Determination: Based on this assessment and combined with the noted functional limitations in one or
more of the following domains: psychological, social, occupational, educational and/or achieving or maintaining housing,
employment, relationships, or safety and Intensity of Need-LOCUS Level I this individual is determined to meet criteria
for SMI status.
CASE FORMULATION (Based on Assessment):

PLAN (must include treatment recommendations and referrals):

Client provided crisis information and reminded to contact this writer with any urgent mental health needs and the mental
health crisis line for any mental health crisis. Case to be staffed and care coordinated at next clinical meeting.
QMHP: AVATAR#: