Initial Psychiatric Assessment
ADVERTISEMENT
1
2
3
4
5NAME/MRN:
B
H
D
EHAVIORAL
EALTH
IVISION
INITIAL PSYCHIATRIC ASSESSMENT
DATE OF SERVICE _________________________
RU# ___________________
STAFF #
_____________________________
HOURS _______________________ MINUTES ________________
Code Activity:
361 EVAL/RX
Location:
1 Office
2 Field
4 Home
5 School Satellite
18 Other
Service Strategies: (Please check up to three, if applicable)
50 Peer/Fam Deliv Svcs
53 Supportive Education
56 Ptnrshp:Soc Svcs
59 Integrated Svcs:MH-Dvlp Disbled
51 Psych Education
54 Prtnrshp:LawEnfcmt
57 Ptnrshp:Subs Abuse
60 Ethnic-Specific Service Strategy
52 Family Support
55 Ptnrshp:Health Care
58 IntSvcs:MH/Aging
61 Age-Spec Svc Strategy
99 Unknown
Assessment in language other than English:
Spanish
Other ____________________________________
Interpreter
Name of Interpreter: _________________________________
Identifying Information:
Legal Name: ____________________________________________
DOB/Age:______________________
Preferred Name: _________________________________________
Gender:
Male
Female
Transgender F-M
Transgender M-F
Intersex
Other _____
Single
Married
Significant Other
Separated
Divorced
Marital Status:
Address: _________________________________________________
Phone #: ________________________
Emergency Contact / Significant Other: ________________________________________
_________________
Name
Phone
Primary concerns per consumer: _______________________________________________________________
____________________________________________________________________________________________
Presenting Problem/ Recent Course of Illness: ____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Consumer and Family Strengths (Positive factors to facilitate treatment e.g. faith, resilience, etc.):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
1
MHC113Initial Psychiatric Assessment (9/13)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical