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Consumer Name: CID#


Date of Assessment:
What are the presenting problems? Severity, Frequency, and Duration of chief
complaint? Discuss recurring symptoms/behaviors, functional risks? Onset of
problems? (Include relevant psychological and social conditions affecting psychiatric status)

Why seeking treatment now (any early indications or significant behaviors that could be disruptive/risk to
community/family/school, significant)?

Symptoms currently experiencing:

Sleep Disturbance Truancy Impulsivity Aggressive Behavior
Appetite Disturbance Lying/ Manipulative Hyperactivity Binging/Purging
Episodic crying Self-injurious Behavior Sexual Acting Out Anorexia
Low Energy Obsessions/Compulsions Delusions Alcohol Use or Abuse
Depressed Mood Poor Concentration Paranoid Ideations Drug Use or Abuse
Inattentive/Not Mood Liability Loose Associations Bed Wetting
focusing Irritability Hallucinations Social Withdrawal
Feelings of Anxiety/Panic Attacks Suicidal or Homicidal RX Meds
worthlessness Panic Attacks thoughts/behaviors Isolating from others
Runaway behavior Stealing Oppositional/Defiant
Explain details of each above and I/D other symptoms/behaviors not listed (i.e. severity,
frequency, duration):

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. REVJUL 2008

Consumer Name: CID#
Recent Death Relapse
Physical Abuse School
Sexual Abuse Problems
Emotional Custody Issues
Abuse Placement
Recent Issues
Legal Issues

Mental Health Treatment History

□Prior or Current Psychotherapy or Psychiatric Treatment? (Include when, why, with whom, length
and type of treatment, was treatment considered successful, and why was it discontinued)?

□Current or history of psychotropic medication? (Include dosages, frequency, etc.).

□Family History of Mental Health Treatment/Diagnosis?

□Ever hospitalized in an in-patient facility? State when and where.

□History of Suicide Attempts?

□History of self-injury/self-mutilation??

Medical History
□Name of Current Physician/ or Practice Name:
□Date of last physical?
□Are immunizations up to date? Yes No
□Passed Vision Screen? Yes No
□Passed Hearing Screen? Yes No
□Results of last dental exam?
□Any Medical Condition (s)? Yes No
If yes, what effect medical condition has on consumer’s level of physical functioning and mental
□Current medication(s)?
□Any significant Family Medical History?

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. REVJUL 2008

Family History

Current Relationship: (children & adolescents inquire about their parents, if applicable)
Married Domestic Partner Separated Single None
Discuss length, history, status of relationship, supportive, problems:

List Names of other children in the family and their ages:

1) Age: 5) Age:
2) Age: 6) Age:
3) Age: 7) Age:
4) Age: 8) Age:

Consumers Birth Order: of children born to natural parents

of adopted by parents

Siblings (natural and blended family structures):

Name/Gender Age:
Name/Gender Age:
Name/Gender Age:
Name/Gender Age:

Number of family members who currently live in the household:

(List names if they are not listed above)

Consumer was born and raised where, what hospital, by whom:

Skill/Ability Assessment
Personal Hygiene Coping Skills/ Emotional Mgmt
Household Tasks Childcare/Parenting
Cooking/Nutrition Financial Management
Personal Safety Medical/Medication Mgmt
Leisure/Recreational Mobility Within Community
Social/Family Relations Specify Other
Needs/ Resource Assessment
Housing Transportation
Family/Social Support Education
Community Involvement/Support Vocational
Financial Specify Other
Healthcare Specify Other
Abilities, Willingness to participate & Responsibility
Consumer Overall Attitude Towards Treatment

Preferences/Hopes for Recovery (in consumer’s own words)

Educational History
1. Last grade level completed:
2. School setting? Type of Classroom Placement:
3. Number and grade levels of retentions:
4. Is the student support team (SST) currently serving the child? Yes No
5. Does the child have an IEP? Yes No
6. Rate the child’s attendance in school and also give the number of days absent in the last 30 days
(request and review the school records if needed).

Mental Status Exam (check all that apply)

Attention Good Fair ( task 78%) Easily Distracted Highly Distractible

Affect Appropriate Labile Expansive Constricted Blunted
Mood Normal Depressed Anxious Euphoric
Appearance Well-groomed Disheveled Bizarre Inappropriate
Motor Activity Calm Hyperactive Agitated Tremors Tics Muscle Spasms
Thought Process Intact Circumstantial Tangential Flight of Ideas Loose Associations
Hallucination None Auditory Visual Olfactory Command
Delusions None Persecutory Grandiose Religious Other _________________
Memory Intact Impaired Immediate Recent Remote
Judgment/Insight Intact Impaired: Mild Moderate Severe
Orientation All Spheres Impaired: Person Place Time Purpose
Suicidal None Ideation Plan Intent Means
Homicidal None Ideation Plan Intent Means
Speech Normal Slow Slurred Pressured Rapid

Other Comments:

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008
Functional Impairments
(Estimate the effect behavioral problems or emotional distress has on the following):

Family None Mild Moderate Severe

Relationship with S/O & other Primary R/T None Mild Moderate Severe
Physical Health None Mild Moderate Severe
Work None Mild Moderate Severe
School None Mild Moderate Severe
Spiritual/Sense of Meaning None Mild Moderate Severe
Social/Activity Level None Mild Moderate Severe

Addiction/Chemical Use & Dependency Assessment

(Include tobacco, alcohol, RX, abuse, over the counter and illicit drugs and relevant caffeine)

Name of Drug Frequency Amount Age & Years Started


Currently By hx

Currently By hx

Currently By hx

Currently By hx

□ Which is primary drug of choice, secondary, and third (if applicable)?

□ Last Use? (What drug did you experience recently, how long ago, how much)

□ Have received prior treatment for this issue (who, when, where, outcome):

□ Family History of Addiction/Chemical Abuse Treatment?

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008
Criminal/Legal History

□ Discuss all past or recent criminal/illegal acts, charges, arrests, etc.?

□ On Parole? If yes, give details:

□ On Probation? If yes, give details and obtain name of PO and a contact number:

□ Court mandated (Criminal, Family Court, or Juvenile Court)

□ Other Status


AXIS I: (Primary)

AXIS I: (Secondary)




AXIS V: Current GAF _______ Highest GAF in the Past Year ______


1. 3.

2. 4.

Signature and Credentials Print Name and Credentials Date

BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008