Demographics

+-------------------------------------+------------+-------------------+
| Client Name: **     **              | # D        |                   |
|                                     | ate:       |                   |
+-------------------------------------+------------+-------------------+
| # Current Address:                  | #          |                   |
|                                     | Phone #: ( |                   |
| Street                              |      )     |                   |
|                                     |    -       |                   |
| City, State                         |            |                   |
|                                     |            |                   |
| Zip Code                            |            |                   |
+-------------------------------------+------------+-------------------+
| # Date of Birth:                    | # Mari     |                   |
|                                     | tal/Relati |                   |
|                                     | onship Sta |                   |
|                                     | tus:       |                   |
+-------------------------------------+------------+-------------------+
| # Nation/Tribe/Ethnicity:           |            |                   |
+-------------------------------------+------------+-------------------+
| **Primary language of client:**     |            | **Secondary:**    |
|                                     |            |                   |
+-------------------------------------+------------+-------------------+
| **Referral Source:**                |            | **Phone:**        |
+-------------------------------------+------------+-------------------+
| **Emergency Contact:      **        |            | **Phone:      **  |
+-------------------------------------+------------+-------------------+

Critical Population (choose all that apply)

+-------------------+---+-----------------------+-----+----------------+
| ####              | # |                       | ### |                |
| ## Funding Source | # |                       | ### |                |
|                   | # |                       |  Le |                |
|                   | # |                       | gal |                |
|                   | # |                       |  In |                |
|                   | # |                       | vol |                |
|                   |   |                       | vem |                |
|                   | R |                       | ent |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | i |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Food Stamp        | H |                       | P   |                |
| Recipient         | o |                       | rot |                |
|                   | m |                       | ect |                |
|                   | e |                       | ive |                |
|                   | l |                       | Se  |                |
|                   | e |                       | rvi |                |
|                   | s |                       | ces |                |
|                   | s |                       | (AP |                |
|                   |   |                       | S/C |                |
|                   |   |                       | PS) |                |
+-------------------+---+-----------------------+-----+----------------+
| TANF Recipient    | S |                       | Co  |                |
|                   | h |                       | urt |                |
|                   | e |                       | O   |                |
|                   | l |                       | rde |                |
|                   | t |                       | red |                |
|                   | e |                       | Se  |                |
|                   | r |                       | rvi |                |
|                   | R |                       | ces |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSI Recipient     | L |                       | On  |                |
|                   | o |                       | Pro |                |
|                   | n |                       | bat |                |
|                   | g |                       | ion |                |
|                   | T |                       |     |                |
|                   | e |                       |     |                |
|                   | r |                       |     |                |
|                   | m |                       |     |                |
|                   | C |                       |     |                |
|                   | a |                       |     |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | E |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | g |                       |     |                |
|                   | i |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSDI Recipient    | L |                       | On  |                |
|                   | o |                       | Par |                |
|                   | n |                       | ole |                |
|                   | g |                       |     |                |
|                   | T |                       |     |                |
|                   | e |                       |     |                |
|                   | r |                       |     |                |
|                   | m |                       |     |                |
|                   | C |                       |     |                |
|                   | a |                       |     |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | R |                       |     |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSA (retirement)  |   |                       | On  |                |
| Recipient         |   |                       | Pr  |                |
|                   |   |                       | e-R |                |
|                   |   |                       | ele |                |
|                   |   |                       | ase |                |
+-------------------+---+-----------------------+-----+----------------+
| Other Retirement  | # |                       | Man |                |
| Income            | # |                       | dat |                |
|                   | # |                       | ory |                |
|                   | # |                       | M   |                |
|                   | # |                       | oni |                |
|                   | # |                       | tor |                |
|                   |   |                       | ing |                |
|                   | D |                       |     |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Medicaid          | P |                       |     |                |
| Recipient         | h |                       |     |                |
|                   | y |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | c |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | D |                       |     |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Medicare          | S |                       | ### |                |
| Recipient         | e |                       | ### |                |
|                   | v |                       |  Ot |                |
|                   | e |                       | her |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | M |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | I |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| General           | S |                       | Cur |                |
| Assistance        | E |                       | ren |                |
|                   | D |                       | tly |                |
|                   |   |                       | pr  |                |
|                   |   |                       | egn |                |
|                   |   |                       | ant |                |
+-------------------+---+-----------------------+-----+----------------+
|                   | D |                       | Wo  |                |
|                   | e |                       | man |                |
|                   | v |                       | w/d |                |
|                   | e |                       | epe |                |
|                   | l |                       | nde |                |
|                   | o |                       | nts |                |
|                   | p |                       |     |                |
|                   | m |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | D |                       |     |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | l |                       |     |                |
|                   | e |                       |     |                |
|                   | d |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   | C |                       |     |                |
|                   | h |                       |     |                |
|                   | r |                       |     |                |
|                   | o |                       |     |                |
|                   | n |                       |     |                |
|                   | i |                       |     |                |
|                   | c |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | M |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | I |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   | R |                       |     |                |
|                   | e |                       |     |                |
|                   | g |                       |     |                |
|                   | i |                       |     |                |
|                   | o |                       |     |                |
|                   | n |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | B |                       |     |                |
|                   | e |                       |     |                |
|                   | h |                       |     |                |
|                   | a |                       |     |                |
|                   | v |                       |     |                |
|                   | i |                       |     |                |
|                   | o |                       |     |                |
|                   | r |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | H |                       |     |                |
|                   | e |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | t |                       |     |                |
|                   | h |                       |     |                |
|                   | A |                       |     |                |
|                   | u |                       |     |                |
|                   | t |                       |     |                |
|                   | h |                       |     |                |
|                   | o |                       |     |                |
|                   | r |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| ###### Co         |   |                       |     |                |
| ntact Information |   |                       |     |                |
|                   |   |                       |     |                |
| **(Secure         |   |                       |     |                |
| consents for      |   |                       |     |                |
| agency contacts,  |   |                       |     |                |
| when possible)**  |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| # N               |   | **Agency**            |     | **Phone        |
| ame of Caseworker |   |                       |     | number**       |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+

# 

# Vocational/Employment Screening

+------+-----+---+---------+------+-----+------+---------------------+
| ##   |     |   |         |      |     |      |                     |
| #### |     |   |         |      |     |      |                     |
|  Emp |     |   |         |      |     |      |                     |
| loym |     |   |         |      |     |      |                     |
| ent: |     |   |         |      |     |      |                     |
|  Cur |     |   |         |      |     |      |                     |
| rent |     |   |         |      |     |      |                     |
| ly E |     |   |         |      |     |      |                     |
| mplo |     |   |         |      |     |      |                     |
| yed? |     |   |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| ##   | ##  |   |         |      |     | #    |                     |
| #### | ### |   |         |      |     | #### |                     |
|  Yes | # E |   |         |      |     | # Le |                     |
|      | mpl |   |         |      |     | ngth |                     |
|      | oye |   |         |      |     |  of  |                     |
|      | r   |   |         |      |     | Empl |                     |
|      |     |   |         |      |     | oyme |                     |
|      |     |   |         |      |     | nt   |                     |
|      |     |   |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| #### |     | # |         | ##   |     |      | ######              |
| ## S |     | # |         | #### |     |      |  Co-worker Conflict |
| atis |     | # |         |  Sup |     |      |                     |
| fied |     | # |         | ervi |     |      |                     |
|      |     | # |         | sor  |     |      |                     |
|      |     | # |         | Conf |     |      |                     |
|      |     |   |         | lict |     |      |                     |
|      |     | D |         |      |     |      |                     |
|      |     | i |         |      |     |      |                     |
|      |     | s |         |      |     |      |                     |
|      |     | s |         |      |     |      |                     |
|      |     | a |         |      |     |      |                     |
|      |     | t |         |      |     |      |                     |
|      |     | i |         |      |     |      |                     |
|      |     | s |         |      |     |      |                     |
|      |     | f |         |      |     |      |                     |
|      |     | i |         |      |     |      |                     |
|      |     | e |         |      |     |      |                     |
|      |     | d |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| #    | ### |   |         |      |     | ##   |                     |
| #### | ### |   |         |      |     | #### |                     |
| # No |  La |   |         |      |     |  Rea |                     |
|      | st  |   |         |      |     | son  |                     |
|      | Emp |   |         |      |     | for  |                     |
|      | loy |   |         |      |     | Leav |                     |
|      | er: |   |         |      |     | ing: |                     |
|      |     |   |         |      |     |      |                     |
|      |     |   |         |      |     |      |                     |
|      |     |   |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| #    |     |   | #       |      | ##  |      | ###### Un           |
| #### |     |   | ##### D |      | ### |      | stable Work History |
| # Ne |     |   | isabled |      | # S |      |                     |
| ver  |     |   |         |      | tud |      |                     |
| Empl |     |   |         |      | ent |      |                     |
| oyed |     |   |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| #### |     |   |         |      | #   |      |                     |
| ##   |     |   |         |      | ### |      |                     |
| Shel |     |   |         |      | ##  |      |                     |
| tere |     |   |         |      |  Re |      |                     |
| d Em |     |   |         |      | cei |      |                     |
| ploy |     |   |         |      | vin |      |                     |
| ment |     |   |         |      | g V |      |                     |
|      |     |   |         |      | oca |      |                     |
|      |     |   |         |      | tio |      |                     |
|      |     |   |         |      | nal |      |                     |
|      |     |   |         |      |  Se |      |                     |
|      |     |   |         |      | rvi |      |                     |
|      |     |   |         |      | ces |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+
| #### |     |   |         |      |     |      |                     |
| ## C |     |   |         |      |     |      |                     |
| omme |     |   |         |      |     |      |                     |
| nts: |     |   |         |      |     |      |                     |
|      |     |   |         |      |     |      |                     |
|      |     |   |         |      |     |      |                     |
|      |     |   |         |      |     |      |                     |
+------+-----+---+---------+------+-----+------+---------------------+

Family Relationships

<table style="width:100%;">
<colgroup>
<col style="width: 30%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 19%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><h1 id="section-1"></h1>
<h1 id="does-the-client-have-any-children">Does the client have any
children?</h1></td>
</tr>
<tr class="even">
<td colspan="2"><h1 id="name">Name</h1></td>
<td colspan="2"><h1 id="age">Age</h1></td>
<td><strong>Date of Birth</strong></td>
<td colspan="2"><h1 id="sex">Sex</h1></td>
<td><h1 id="custody">Custody?</h1>
<h1 id="yn">Y/N</h1></td>
<td colspan="3"><h1 id="lives-with">Lives With?</h1></td>
<td><h1 id="additional-information">Additional Information</h1></td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="12"><h1 id="section-2"></h1></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Who else lives with the client? (Include
spouses, partners, siblings, parents, other relatives,
friends)</strong></td>
</tr>
<tr class="odd">
<td><strong>Name</strong></td>
<td colspan="2"><strong>Age</strong></td>
<td colspan="3"><h1 id="sex-1">Sex</h1></td>
<td colspan="4"><h1 id="relationship">Relationship</h1></td>
<td colspan="2"><h1 id="additional-information-1">Additional
Information</h1></td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="9"><strong>Primary language of household/family:
    </strong></td>
<td colspan="3"><strong>Secondary:      </strong></td>
</tr>
</tbody>
</table>

  -----------------------------------------------------------------------
  **Client's/Family's Presentation of the Problem:**      

  **Client's/Family's Expected Outcome:**      
  -----------------------------------------------------------------------

+----------------------------------------------------+--------+-------+
| Physical                                           | Yes    | No    |
+----------------------------------------------------+--------+-------+
| Client states that he/she has an exercise program. |        |       |
| *Optional - Physical Fitness*                      |        |       |
+----------------------------------------------------+--------+-------+
| Client reports appropriate interventions taken     |        |       |
| when experiencing illness or injury.               |        |       |
+----------------------------------------------------+--------+-------+
| Client engages in preventive medicine activities   |        |       |
| such as breast or testes self-examination.         |        |       |
+----------------------------------------------------+--------+-------+
| Client receives an adequate amount of sleep. *If   |        |       |
| No, explain below in Comments section*             |        |       |
+----------------------------------------------------+--------+-------+
| Client avoids the use of tobacco products or       |        |       |
| exposure to second-hand smoke. *If NO, complete    |        |       |
| Behavioral Assessment*                             |        |       |
+----------------------------------------------------+--------+-------+
| Client consumes no more than two alcoholic drinks  |        |       |
| per day. *If NO, complete Behavioral Assessment*   |        |       |
+----------------------------------------------------+--------+-------+
| Allergies (Medication and Other):                  |        |       |
+----------------------------------------------------+--------+-------+
| Additional Information:                            |        |       |
|                                                    |        |       |
|                                                    |        |       |
+----------------------------------------------------+--------+-------+

# Nutrition 

+----------------------------------------+-----------------------------+
| ######  {#section-3}                   |                             |
|                                        |                             |
| ##                                     |                             |
| #### Nutritional Status: Current Weigh |                             |
| t       Current Height       BMI       |                             |
+----------------------------------------+-----------------------------+
| ###### Appetite:                       |                             |
| Good  Fair  Poor, please explain below |                             |
+----------------------------------------+-----------------------------+
| ######  R                              | ######                      |
| ecently gained/lost significant weight |   Binges/overeats to excess |
+----------------------------------------+-----------------------------+
| ######  Restricts food/Vomi            | ##                          |
| ts/over-exercises to avoid weight gain | ####  Special dietary needs |
+----------------------------------------+-----------------------------+
| ######  Hiding/hording food            | ######  Food allergies      |
+----------------------------------------+-----------------------------+
| ###### Comments                        |                             |
|                                        |                             |
|                                        |                             |
+----------------------------------------+-----------------------------+

# Pain Questionnaire

+-----------------------------------------------------------------------+
| ######  {#section-4}                                                  |
|                                                                       |
| ###### Pain Management: Is the client in pain now?  Yes  No           |
|                                                                       |
| If yes, ask client to rate the pain on a scale of 1-10 (with 10 being |
| the severest) and                                                     |
|                                                                       |
| enter score here                                                      |
|                                                                       |
| ######  Is the client receiving care for the pain?  Yes  No           |
|                                                                       |
| ######  I                                                             |
| f no, would the client like a referral for pain management?  Yes  No  |
+-----------------------------------------------------------------------+

Family History

+------------------------+------+-----+------+-----+------+----------+
| #####                  |      |     |      |     |      |          |
| # Family History of (s |      |     |      |     |      |          |
| elect all that apply): |      |     |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  {#section-5}   | #    | #   | ###  | ##  | #    | ###      |
|                        | #### | ### | ###  | ### | #### | ### Gran |
|                        | # Mo | ##  | Sibl | # A | # Un | dparents |
|                        | ther | Fat | ings | unt | cle  |          |
|                        |      | her |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### A               | #### | ##  | #### | ##  | #    | #####    |
| lcohol/Substance Abuse | ##   | ### | ##   | ### | #### | #  {#sec |
|                        | {#se | #   | {#se | #   | #  { | tion-11} |
|                        | ctio | {#s | ctio | {#s | #sec |          |
|                        | n-6} | ect | n-8} | ect | tion |          |
|                        |      | ion |      | ion | -10} |          |
|                        |      | -7} |      | -9} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### Histor          | #    | ### | #    | ### | #    | #####    |
| y of Completed Suicide | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-17} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -12} | on- | -14} | on- | -16} |          |
|                        |      | 13} |      | 15} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######                 | #    | ### | #    | ### | #    | #####    |
|  History of Mental Ill | #### | ### | #### | ### | #### | #  {#sec |
| ness/Problems such as: | #  { |   { | #  { |   { | #  { | tion-23} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -18} | on- | -20} | on- | -22} |          |
|                        |      | 19} |      | 21} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Depression     | #    | ### | #    | ### | #    | #####    |
|                        | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-29} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -24} | on- | -26} | on- | -28} |          |
|                        |      | 25} |      | 27} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Schizophrenia  | #    | ### | #    | ### | #    | #####    |
|                        | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-35} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -30} | on- | -32} | on- | -34} |          |
|                        |      | 31} |      | 33} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ##                     | #    | ### | #    | ### | #    | #####    |
| ####  Bipolar Disorder | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-41} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -36} | on- | -38} | on- | -40} |          |
|                        |      | 37} |      | 39} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Alzheimer's    | #    | ### | #    | ### | #    | #####    |
|                        | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-47} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -42} | on- | -44} | on- | -46} |          |
|                        |      | 43} |      | 45} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Anxiety        | #    | ### | #    | ### | #    | #####    |
|                        | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-53} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -48} | on- | -50} | on- | -52} |          |
|                        |      | 49} |      | 51} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Attention      | #    | ### | #    | ### | #    | #####    |
|  Deficit/Hyperactivity | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-59} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -54} | on- | -56} | on- | -58} |          |
|                        |      | 55} |      | 57} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ####                   | #    | ### | #    | ### | #    | #####    |
| ##  Learning Disorders | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-65} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -60} | on- | -62} | on- | -64} |          |
|                        |      | 61} |      | 63} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Sc             | #    | ### | #    | ### | #    | #####    |
| hool Behavior Problems | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-71} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -66} | on- | -68} | on- | -70} |          |
|                        |      | 67} |      | 69} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Incarceration  | #    | ### | #    | ### | #    | #####    |
|                        | #### | ### | #### | ### | #### | #  {#sec |
|                        | #  { |   { | #  { |   { | #  { | tion-77} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -72} | on- | -74} | on- | -76} |          |
|                        |      | 73} |      | 75} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| #####                  | #    | ### | #    | ### | #    | #####    |
| #  Other\_\_\_\_\_\_\_ | #### | ### | #### | ### | #### | #  {#sec |
| \_\_\_\_\_\_\_\_\_\_\_ | #  { |   { | #  { |   { | #  { | tion-83} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -78} | on- | -80} | on- | -82} |          |
|                        |      | 79} |      | 81} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### Comments:       |      |     |      |     |      |          |
|                        |      |     |      |     |      |          |
|                        |      |     |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+

+-------------------------------------------------------+-------+------+
| # Social                                              | # Yes | # No |
+-------------------------------------------------------+-------+------+
| # Client re                                           | #     | #  { |
| ports satisfaction with his/her family relationships. |   {#s | #sec |
|                                                       | ectio | tion |
|                                                       | n-84} | -85} |
+-------------------------------------------------------+-------+------+
| # Client reports satisfact                            | #     | #  { |
| ion with his/her social relationships and activities. |   {#s | #sec |
|                                                       | ectio | tion |
|                                                       | n-86} | -87} |
+-------------------------------------------------------+-------+------+
| # Client reports satisfaction with the                | #     | #  { |
| entertainment/recreational activities he/she selects. |   {#s | #sec |
|                                                       | ectio | tion |
|                                                       | n-88} | -89} |
+-------------------------------------------------------+-------+------+
| # Client expresses an                                 | #     | #  { |
|  interest in his community and the world, in general. |   {#s | #sec |
|                                                       | ectio | tion |
|                                                       | n-90} | -91} |
+-------------------------------------------------------+-------+------+
| # Client has a history of or current legal inv        | #     | #  { |
| olvement. *If Yes), complete Legal Status Screening.* |   {#s | #sec |
|                                                       | ectio | tion |
|                                                       | n-92} | -93} |
+-------------------------------------------------------+-------+------+
| # Comments:                                           |       |      |
|                                                       |       |      |
|                                                       |       |      |
+-------------------------------------------------------+-------+------+

# Functional Assessment 

+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Is c     |   |   |           |   |        |     |     |          |
| lient able to c |   |   |           |   |        |     |     |          |
| are for him/her |   |   |           |   |        |     |     |          |
| self?  Yes  No  |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
| If No, please   |   |   |           |   |        |     |     |          |
| explain:        |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Li       |   |   |           |   |        |     |     |          |
| ving Situation: |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Ho       |   | # |           |   | ##     |     |     | ######   |
| using Adequate  |   | # |           |   | #### H |     |     | Homeless |
|                 |   | # |           |   | ousing |     |     |          |
|                 |   | # |           |   |  Overc |     |     |          |
|                 |   | # |           |   | rowded |     |     |          |
|                 |   | # |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | H |           |   |        |     |     |          |
|                 |   | o |           |   |        |     |     |          |
|                 |   | u |           |   |        |     |     |          |
|                 |   | s |           |   |        |     |     |          |
|                 |   | i |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | g |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | D |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | g |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | o |           |   |        |     |     |          |
|                 |   | u |           |   |        |     |     |          |
|                 |   | s |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Depend   |   | # |           |   | ###    |     |     |          |
| ent Upon Others |   | # |           |   | ### Wa |     |     |          |
|                 |   | # |           |   | rd of  |     |     |          |
|                 |   | # |           |   | State/ |     |     |          |
|                 |   | # |           |   | Tribal |     |     |          |
|                 |   | # |           |   |  Court |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | I |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | c |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | c |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | t |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | d |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ####            |   |   |           |   |        |     |     |          |
| ## Additional I |   |   |           |   |        |     |     |          |
| nformation:     |   |   |           |   |        |     |     |          |
|    {#additional |   |   |           |   |        |     |     |          |
| -information-2} |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######          |   |   |           |   |        |     |     |          |
|   {#section-94} |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
| ###### Uses or  |   |   |           |   |        |     |     |          |
| Needs assistive |   |   |           |   |        |     |     |          |
|  or adaptive de |   |   |           |   |        |     |     |          |
| vices (select a |   |   |           |   |        |     |     |          |
| ll that apply): |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### None     | # |   |           | # |        |     | ##  |          |
|                 | # |   |           | # |        |     | ### |          |
|                 | # |   |           | # |        |     | # B |          |
|                 | # |   |           | # |        |     | rai |          |
|                 | # |   |           | # |        |     | lle |          |
|                 | # |   |           | # |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 | G |   |           | W |        |     |     |          |
|                 | l |   |           | a |        |     |     |          |
|                 | a |   |           | l |        |     |     |          |
|                 | s |   |           | k |        |     |     |          |
|                 | s |   |           | e |        |     |     |          |
|                 | e |   |           | r |        |     |     |          |
|                 | s |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ####            | # |   |           | # |        |     | ##  |          |
| ## Hearing Aids | # |   |           | # |        |     | ### |          |
|                 | # |   |           | # |        |     | # W |          |
|                 | # |   |           | # |        |     | hee |          |
|                 | # |   |           | # |        |     | lch |          |
|                 | # |   |           | # |        |     | air |          |
|                 |   |   |           |   |        |     |     |          |
|                 | C |   |           | C |        |     |     |          |
|                 | a |   |           | r |        |     |     |          |
|                 | n |   |           | u |        |     |     |          |
|                 | e |   |           | t |        |     |     |          |
|                 |   |   |           | c |        |     |     |          |
|                 |   |   |           | h |        |     |     |          |
|                 |   |   |           | e |        |     |     |          |
|                 |   |   |           | s |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######          |   |   | ###       |   |        | #   |     |          |
| Translated Writ |   |   | ### Trans |   |        | ### |     |          |
| ten Information |   |   | lator for |   |        | ##  |     |          |
|                 |   |   |  Speaking |   |        | Oth |     |          |
|                 |   |   |           |   |        | er: |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Does     |   |   |           |   |        |     |     |          |
|  the client hav |   |   |           |   |        |     |     |          |
| e a history of  |   |   |           |   |        |     |     |          |
| falls?  Yes  No |   |   |           |   |        |     |     |          |
|  Explain:       |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+

# Legal Status Screening

+-----------------------+-----------------------+-----------------------+
| # Past or curre       |                       |                       |
| nt legal problems (se |                       |                       |
| lect all that apply)? |                       |                       |
+-----------------------+-----------------------+-----------------------+
| None                  | Gangs                 | DUI/DWI               |
+-----------------------+-----------------------+-----------------------+
| Arrests               | Conviction            | Detention             |
+-----------------------+-----------------------+-----------------------+
| Jail                  | Probation             | Other:                |
+-----------------------+-----------------------+-----------------------+
| **If yes to any of    |                       |                       |
| the above, please     |                       |                       |
| explain:**            |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **Any court-ordered   |                       |                       |
| treatment?** Yes      |                       |                       |
| (explain below) No    |                       |                       |
+-----------------------+-----------------------+-----------------------+
| ###### Ordered by     | **Offense**           | **Length of Time**    |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+

# Educational Status Screening 

+-----------------------+-----------------------+---+--------------------+
| ###### Educational L  |                       |   | ######  Some coll  |
| evel (select one):  l |                       |   | ege or tech school |
| ess than 12 years --  |                       |   |                    |
| enter grade completed |                       |   |                    |
+-----------------------+-----------------------+---+--------------------+
| ######  Unknown       | ######                | # |                    |
|                       |  High School Grad/GED | # |                    |
|                       |                       | # |                    |
|                       |                       | # |                    |
|                       |                       | # |                    |
|                       |                       | # |                    |
|                       |                       |   |                    |
|                       |                       |   |                    |
|                       |                       | C |                    |
|                       |                       | o |                    |
|                       |                       | l |                    |
|                       |                       | l |                    |
|                       |                       | e |                    |
|                       |                       | g |                    |
|                       |                       | e |                    |
|                       |                       |   |                    |
|                       |                       | G |                    |
|                       |                       | r |                    |
|                       |                       | a |                    |
|                       |                       | d |                    |
|                       |                       | u |                    |
|                       |                       | a |                    |
|                       |                       | t |                    |
|                       |                       | e |                    |
+-----------------------+-----------------------+---+--------------------+
| ###### If st          |                       |   |                    |
| ill attending, curren |                       |   |                    |
| t School/Grade:       |                       |   |                    |
+-----------------------+-----------------------+---+--------------------+
| ###### Vocational Sch |                       |   |                    |
| ool/Skill Area:       |                       |   |                    |
+-----------------------+-----------------------+---+--------------------+
| ###### College/Gradu  |                       |   |                    |
| ate School -- Years C |                       |   |                    |
| ompleted/Major:       |                       |   |                    |
+-----------------------+-----------------------+---+--------------------+

**Leisure & Recreation**

+-----------------------------------+-----------------------------------+
| **Which of the following does the |                                   |
| client do? (Select all that       |                                   |
| apply)**                          |                                   |
+-----------------------------------+-----------------------------------+
| Spend Time with Friends           | Sports/Exercise                   |
+-----------------------------------+-----------------------------------+
| Classes                           | Dancing                           |
+-----------------------------------+-----------------------------------+
| Time with Family                  | Hobbies                           |
+-----------------------------------+-----------------------------------+
| Work Part-Time                    | Watch Movies/TV                   |
+-----------------------------------+-----------------------------------+
| Go "Downtown"                     | Stay at Home                      |
+-----------------------------------+-----------------------------------+
| Listen to Music                   | Spend Time at Clubs/Bars          |
+-----------------------------------+-----------------------------------+
| Go to Casinos                     | Other:                            |
+-----------------------------------+-----------------------------------+
| # What limits the client's        |                                   |
|  leisure/recreational activities? |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+

Family Social History

+-----------------------------------------------------------------------+
| **Describe family relationships & desire for involvement in the       |
| treatment process:**                                                  |
|                                                                       |
|                                                                       |
|                                                                       |
| **Perceived level of support for treatment? (scale 1-5 with 5 being   |
| the most supportive)      **                                          |
+-----------------------------------------------------------------------+

+-----------------------------------------------------+--------+------+
| ### Psychological                                   | ##     | **   |
|                                                     | ## Yes | No** |
+-----------------------------------------------------+--------+------+
| Client accepts responsibility for creating his/her  |        |      |
| own feelings.                                       |        |      |
+-----------------------------------------------------+--------+------+
| Client accepts responsibility for his/her own       |        |      |
| actions.                                            |        |      |
+-----------------------------------------------------+--------+------+
| Client makes decisions with a minimum of stress and |        |      |
| worry.                                              |        |      |
+-----------------------------------------------------+--------+------+
| Client is able to express feelings of anger,        |        |      |
| disappointment, frustration, etc.                   |        |      |
+-----------------------------------------------------+--------+------+
| Client reports a stable emotional life.             |        |      |
+-----------------------------------------------------+--------+------+
| Client feels enthusiastic about his/her life.       |        |      |
+-----------------------------------------------------+--------+------+
| Client reports adequate energy level.               |        |      |
+-----------------------------------------------------+--------+------+
| Client reports sleep is restful & adequate.         |        |      |
+-----------------------------------------------------+--------+------+
| Client reports he/she feels positive about self.    |        |      |
+-----------------------------------------------------+--------+------+
| **Comments:**                                       |        |      |
|                                                     |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+

#  {#section-95}

# Bereavement/Loss & Spiritual Awareness

+-----------------------------------------------------------------------+
| ###### Pleas                                                          |
| e list significant losses, deaths, abandonments, traumatic incidents: |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| #  {#section-96}                                                      |
|                                                                       |
| # Spiritual/Cultural Awareness & Practice                             |
+-----------------------------------------------------------------------+
| #                                                                     |
|  Knowledgeable about traditions, spirituality, or religion?  Yes  No  |
|                                                                       |
| # Comment:                                                            |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| # Practices traditions, spirituality, or religion?  Yes  No           |
|                                                                       |
| # Comment:                                                            |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| # How does client describe his/her spirituality?                      |
+-----------------------------------------------------------------------+
| # Does client see a traditional healer?  Yes  No                      |
|                                                                       |
| # Comment:                                                            |
|                                                                       |
|                                                                       |
|                                                                       |
| #  {#section-97}                                                      |
+-----------------------------------------------------------------------+

Behavioral Assessment

<table>
<colgroup>
<col style="width: 23%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><h6 id="section-98"></h6>
<h6 id="abuseaddiction-chemical-behavioral">Abuse/Addiction – Chemical
&amp; Behavioral</h6></td>
</tr>
<tr class="even">
<td><h6 id="drug">Drug</h6></td>
<td colspan="4"><h6 id="age-first-used">Age First Used</h6></td>
<td colspan="3"><h6 id="age-heaviest-use">Age Heaviest Use</h6></td>
<td colspan="3"><h6
id="recent-pattern-of-use-frequency-amount-etc">Recent Pattern of Use
(frequency &amp; Amount, etc)</h6></td>
<td><h6 id="date-last-used">Date Last Used</h6></td>
</tr>
<tr class="odd">
<td><h6 id="alcohol">Alcohol</h6></td>
<td colspan="4"><h6 id="section-99">     </h6></td>
<td colspan="3"><h6 id="section-100">     </h6></td>
<td colspan="3"><h6 id="section-101">     </h6></td>
<td><h6 id="section-102">     </h6></td>
</tr>
<tr class="even">
<td><h6 id="cannabis">Cannabis</h6></td>
<td colspan="4"><h6 id="section-103">     </h6></td>
<td colspan="3"><h6 id="section-104">     </h6></td>
<td colspan="3"><h6 id="section-105">     </h6></td>
<td><h6 id="section-106">     </h6></td>
</tr>
<tr class="odd">
<td><h6 id="cocaine">Cocaine</h6></td>
<td colspan="4"><h6 id="section-107">     </h6></td>
<td colspan="3"><h6 id="section-108">     </h6></td>
<td colspan="3"><h6 id="section-109">     </h6></td>
<td><h6 id="section-110">     </h6></td>
</tr>
<tr class="even">
<td><h6 id="stimulants-crystal-speed-amphetamines-etc">Stimulants
(crystal, speed, amphetamines, etc)</h6></td>
<td colspan="4"><h6 id="section-111">     </h6></td>
<td colspan="3"><h6 id="section-112">     </h6></td>
<td colspan="3"><h6 id="section-113">     </h6></td>
<td><h6 id="section-114">     </h6></td>
</tr>
<tr class="odd">
<td><h6 id="methamphetamine">Methamphetamine</h6></td>
<td colspan="4"><h6 id="section-115">     </h6></td>
<td colspan="3"><h6 id="section-116">     </h6></td>
<td colspan="3"><h6 id="section-117">     </h6></td>
<td><h6 id="section-118">     </h6></td>
</tr>
<tr class="even">
<td><h6 id="inhalants-gas-paint-glue-etc">Inhalants (gas, paint, glue,
etc)</h6></td>
<td colspan="4"><h6 id="section-119">     </h6></td>
<td colspan="3"><h6 id="section-120">     </h6></td>
<td colspan="3"><h6 id="section-121">     </h6></td>
<td><h6 id="section-122">     </h6></td>
</tr>
<tr class="odd">
<td><h6 id="hallucinogens-lsd-pcp-mushrooms-etc">Hallucinogens (LSD,
PCP, mushrooms, etc)</h6></td>
<td colspan="4"><h6 id="section-123">     </h6></td>
<td colspan="3"><h6 id="section-124">     </h6></td>
<td colspan="3"><h6 id="section-125">     </h6></td>
<td><h6 id="section-126">     </h6></td>
</tr>
<tr class="even">
<td><h6 id="opioids-heroin-narcotics-methadone-etc">Opioids (heroin,
narcotics, methadone, etc)</h6></td>
<td colspan="4"><h6 id="section-127">     </h6></td>
<td colspan="3"><h6 id="section-128">     </h6></td>
<td colspan="3"><h6 id="section-129">     </h6></td>
<td><h6 id="section-130">     </h6></td>
</tr>
<tr class="odd">
<td><h6 id="sedativehypnotics-valium-phenobarb-etc">Sedative/Hypnotics
(Valium, Phenobarb, etc)</h6></td>
<td colspan="4"><h6 id="section-131">     </h6></td>
<td colspan="3"><h6 id="section-132">     </h6></td>
<td colspan="3"><h6 id="section-133">     </h6></td>
<td><h6 id="section-134">     </h6></td>
</tr>
<tr class="even">
<td><h6
id="designer-drugsother-herbal-steroids-cough-syrup-etc">Designer
Drugs/Other (herbal, Steroids, cough syrup, etc)</h6></td>
<td colspan="4"><h6 id="section-135">     </h6></td>
<td colspan="3"><h6 id="section-136">     </h6></td>
<td colspan="3"><h6 id="section-137">     </h6></td>
<td><h6 id="section-138">     </h6></td>
</tr>
<tr class="odd">
<td><h6 id="tobacco-smoke-chew">Tobacco (smoke, chew)</h6></td>
<td colspan="4"><h6 id="section-139">     </h6></td>
<td colspan="3"><h6 id="section-140">     </h6></td>
<td colspan="3"><h6 id="section-141">     </h6></td>
<td><h6 id="section-142">     </h6></td>
</tr>
<tr class="even">
<td><h6 id="caffeine">Caffeine</h6></td>
<td colspan="4"><h6 id="section-143">     </h6></td>
<td colspan="3"><h6 id="section-144">     </h6></td>
<td colspan="3"><h6 id="section-145">     </h6></td>
<td><h6 id="section-146">     </h6></td>
</tr>
<tr class="odd">
<td colspan="8"><h6 id="ever-injected-drugs-yes-no">Ever injected Drugs?
Yes No</h6></td>
<td colspan="4"><h6 id="if-yes-which-ones">If Yes, Which ones?
     </h6></td>
</tr>
<tr class="even">
<td colspan="12"><h6 id="drug-of-choice">Drug of Choice?      </h6></td>
</tr>
<tr class="odd">
<td colspan="12"><h6 id="section-147"></h6>
<h6
id="consequences-as-a-result-of-drugalcohol-use-select-all-that-apply">Consequences
as a Result of Drug/Alcohol Use (select all that apply)</h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="hangovers"> Hangovers</h6></td>
<td colspan="4"><h6 id="dtsshakes"> DTs/Shakes</h6></td>
<td colspan="4"><h6 id="blackouts"> Blackouts</h6></td>
<td colspan="2"><h6 id="binges"> Binges</h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="overdoses"> Overdoses</h6></td>
<td colspan="4"><h6 id="increased-tolerance-need-more-to-get-high">
Increased Tolerance (need more to get high)</h6></td>
<td colspan="4"><h6 id="gi-bleeding"> GI Bleeding</h6></td>
<td colspan="2"><h6 id="liver-disease"> Liver Disease</h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="sleep-problems"> Sleep Problems</h6></td>
<td colspan="4"><h6 id="seizures"> Seizures</h6></td>
<td colspan="4"><h6 id="relationship-problems"> Relationship
Problems</h6></td>
<td colspan="2"><h6 id="left-school"> Left School</h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="lost-job"> Lost Job</h6></td>
<td colspan="4"><h6 id="duis"> DUIs</h6></td>
<td colspan="4"><h6 id="assaults"> Assaults</h6></td>
<td colspan="2"><h6 id="arrests"> Arrests</h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="incarcerations"> Incarcerations</h6></td>
<td colspan="4"><h6 id="homicide"> Homicide</h6></td>
<td colspan="6"><h6 id="other-2"> Other:      </h6></td>
</tr>
<tr class="odd">
<td colspan="6"><h6 id="longest-period-of-sobriety">Longest Period of
Sobriety?      </h6></td>
<td colspan="6"><h6 id="how-long-ago">How long ago?      </h6></td>
</tr>
<tr class="even">
<td colspan="12"><h6 id="triggers-to-use-list-all-that-apply">Triggers
to use (list all that apply):      </h6></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Has client traded sex for drugs?</strong> No
Yes, explain:      </td>
</tr>
<tr class="even">
<td colspan="12"><strong>Has client been tested for HIV?</strong> Yes
No</td>
</tr>
<tr class="odd">
<td colspan="7"><strong>If yes, date of last test:</strong>      </td>
<td colspan="5"><strong>Results:</strong>      </td>
</tr>
<tr class="even">
<td colspan="12"><strong>Has client had any of the following problem
gambling behaviors?</strong> Select all that apply:</td>
</tr>
<tr class="odd">
<td colspan="4"> Gambled longer than planned</td>
<td colspan="8"> Gambled until last dollar was gone</td>
</tr>
<tr class="even">
<td colspan="4"> Lost sleep thinking of gambling</td>
<td colspan="8"> Used income or savings to gamble while letting bills go
unpaid</td>
</tr>
<tr class="odd">
<td colspan="4"> Borrowed money to gamble</td>
<td colspan="8"> Made repeated, unsuccessful attempts to stop
gambling</td>
</tr>
<tr class="even">
<td colspan="4"> Been remorseful after gambling</td>
<td colspan="8"> Broken the law or considered breaking the law to
finance gambling</td>
</tr>
<tr class="odd">
<td colspan="4"> Other:      </td>
<td colspan="8"> Gambled to get money to meet financial obligations</td>
</tr>
<tr class="even">
<td colspan="12"><strong>Risk Taking/Impulsive Behavior (current/past) –
select all that apply:</strong></td>
</tr>
<tr class="odd">
<td colspan="3"><h6 id="unprotected-sex"> Unprotected sex</h6></td>
<td colspan="6"><h6 id="shoplifting"> Shoplifting</h6></td>
<td colspan="3"><h6 id="reckless-driving"> Reckless driving</h6></td>
</tr>
<tr class="even">
<td colspan="3"><h6 id="gang-involvement"> Gang Involvement</h6></td>
<td colspan="6"><h6 id="drug-dealing"> Drug Dealing</h6></td>
<td colspan="3"><h6 id="carryingusing-weapon"> Carrying/using
weapon</h6></td>
</tr>
<tr class="odd">
<td colspan="12"><h6 id="other-3"> Other:      </h6></td>
</tr>
</tbody>
</table>

**Abuse/Neglect/Exploitation Assessment**

+-------------------------------+-----------------+--------+----------+
| ###### Hist                   |                 |        |          |
| ory of neglect (emotional, nu |                 |        |          |
| tritional, medical, education |                 |        |          |
| al) or exploitation?  No  Yes |                 |        |          |
|                               |                 |        |          |
| ######                        |                 |        |          |
| If yes, please explain:       |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Has clie               |                 |        |          |
| nt been abused at any time in |                 |        |          |
|  the past or present by famil |                 |        |          |
| y, significant others, or any |                 |        |          |
| one else?)  No  Yes, explain: |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Type of Abuse          | ###### By Whom  | ####   | ######   |
|                               |                 | ## Cli | Currentl |
|                               |                 | ent's  | y Occurr |
|                               |                 | Age(s) | ing? Y/N |
+-------------------------------+-----------------+--------+----------+
| ###### Verbal Putdowns        | ######          | ###    | ###      |
|                               |  {#section-148} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-150} |
|                               |                 | n-149} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Being threatened       | ######          | ###    | ###      |
|                               |  {#section-151} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-153} |
|                               |                 | n-152} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Made to feel afraid    | ######          | ###    | ###      |
|                               |  {#section-154} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-156} |
|                               |                 | n-155} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Pushed                 | ######          | ###    | ###      |
|                               |  {#section-157} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-159} |
|                               |                 | n-158} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Shoved                 | ######          | ###    | ###      |
|                               |  {#section-160} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-162} |
|                               |                 | n-161} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Slapped                | ######          | ###    | ###      |
|                               |  {#section-163} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-165} |
|                               |                 | n-164} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Kicked                 | ######          | ###    | ###      |
|                               |  {#section-166} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-168} |
|                               |                 | n-167} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Strangled              | ######          | ###    | ###      |
|                               |  {#section-169} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-171} |
|                               |                 | n-170} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Hit                    | ######          | ###    | ###      |
|                               |  {#section-172} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-174} |
|                               |                 | n-173} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Forced or              | ######          | ###    | ###      |
|  coerced into sexual activity |  {#section-175} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-177} |
|                               |                 | n-176} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Other       {#other-4} | ######          | ###    | ###      |
|                               |  {#section-178} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-180} |
|                               |                 | n-179} |          |
+-------------------------------+-----------------+--------+----------+
| ######  {#section-181}        | ######          |        |          |
|                               |  {#section-182} |        |          |
| ###                           |                 |        |          |
| ### Was it reported?  Yes  No | ######          |        |          |
|                               |  To whom?       |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Outcome                |                 |        |          |
|                               |                 |        |          |
|                               |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Has client e           |                 |        |          |
| ver witnessed abuse or family |                 |        |          |
|  violence?  No  Yes, explain: |                 |        |          |
|                               |                 |        |          |
|                               |                 |        |          |
+-------------------------------+-----------------+--------+----------+

+-----------------------------------------------------+--------+------+
| # Strengths/Weaknesses                              | *      | **   |
|                                                     | *Yes** | No** |
+-----------------------------------------------------+--------+------+
| Client is able to seek out appropriate resources    |        |      |
| for assistance with identified problems.            |        |      |
+-----------------------------------------------------+--------+------+
| Client is able to identify both his/her strengths   |        |      |
| and weaknesses.                                     |        |      |
+-----------------------------------------------------+--------+------+
| **Comments:**                                       |        |      |
+-----------------------------------------------------+--------+------+
| **Strengths/Resources (enter score if present)** 1  |        |      |
| = Adequate, 2 = Above Average, 3 = Exceptional      |        |      |
|                                                     |        |      |
|   -------------------                               |        |      |
| ---------- -------------------- ------------------- |        |      |
|        Family Suppo                                 |        |      |
| rt                Social Support       Relationship |        |      |
|                                                     |        |      |
|                      Systems              Stability |        |      |
|                                                     |        |      |
|        Intellect                                    |        |      |
| ual/Cognitive        Coping Skills &      Parenting |        |      |
|   Skills                                            |        |      |
|                         Resiliency           Skills |        |      |
|                                                     |        |      |
|        Socio-Eco                                    |        |      |
| nomic Stability      Communication        Insight & |        |      |
|                                                     |        |      |
|                    Skills               Sensitivity |        |      |
|                                                     |        |      |
|        Maturity & J                                 |        |      |
| udgment           Motivation for       Other:       |        |      |
|                                                     |        |      |
| Skills                        Help                  |        |      |
|   -------------------                               |        |      |
| ---------- -------------------- ------------------- |        |      |
|                                                     |        |      |
| **Comments:**                                       |        |      |
+-----------------------------------------------------+--------+------+
| **Describe appropriateness & level of need for the  |        |      |
| family's participation:**                           |        |      |
+-----------------------------------------------------+--------+------+

Mental Status Exam

<table>
<colgroup>
<col style="width: 16%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td><h2 id="category"><strong>Category</strong></h2></td>
<td colspan="18"><h3 id="selections">Selections</h3></td>
</tr>
<tr class="even">
<td colspan="19"><strong>GENERAL OBSERVATIONS</strong></td>
</tr>
<tr class="odd">
<td><h2 id="appearance"><strong>Appearance</strong></h2></td>
<td colspan="3"> Well groomed</td>
<td colspan="6"> Unkempt</td>
<td colspan="6"> Disheveled</td>
<td colspan="3"> Malodorous</td>
</tr>
<tr class="even">
<td><strong>Build</strong></td>
<td colspan="3"> Average</td>
<td colspan="6"> Thin</td>
<td colspan="6"> Overweight</td>
<td colspan="3"> Obese</td>
</tr>
<tr class="odd">
<td rowspan="2"><strong>Demeanor</strong></td>
<td colspan="3"> Cooperative</td>
<td colspan="6"> Hostile</td>
<td colspan="6"> Guarded</td>
<td colspan="3"> Withdrawn</td>
</tr>
<tr class="even">
<td colspan="7"> Preoccupied</td>
<td colspan="7"> Demanding</td>
<td colspan="4"> Seductive</td>
</tr>
<tr class="odd">
<td><strong>Eye Contact</strong></td>
<td colspan="7"> Average</td>
<td colspan="7"> Decreased</td>
<td colspan="4"> Increased</td>
</tr>
<tr class="even">
<td><strong>Activity</strong></td>
<td colspan="7"> Average</td>
<td colspan="7"> Decreased</td>
<td colspan="4"> Increased</td>
</tr>
<tr class="odd">
<td rowspan="3"><strong>Speech</strong></td>
<td colspan="3"> Clear</td>
<td colspan="6"> Slurred</td>
<td colspan="6"> Rapid</td>
<td colspan="3"> Slow</td>
</tr>
<tr class="even">
<td colspan="3"> Pressured</td>
<td colspan="6"> Soft</td>
<td colspan="6"> Loud</td>
<td colspan="3"> Monotone</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td colspan="19"><strong>THOUGHT CONTENT</strong></td>
</tr>
<tr class="odd">
<td><strong>Delusions</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Grandiose</td>
<td colspan="6"> Persecutory</td>
<td colspan="2"> Somatic</td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="6"> Bizarre</td>
<td colspan="7"> Nihilist</td>
<td colspan="5"> Religious</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td rowspan="4"><strong>Other</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Poverty of Content</td>
<td colspan="6"> Obsessions</td>
<td colspan="2"> Compulsions</td>
</tr>
<tr class="odd">
<td colspan="4"> Phobias</td>
<td colspan="6"> Guilt</td>
<td colspan="6"> Anhedonia</td>
<td colspan="2">Thought Insertion</td>
</tr>
<tr class="even">
<td colspan="10"> Ideas of Reference</td>
<td colspan="8"> Thought Broadcasting</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td rowspan="2"><strong>Self Abuse</strong></td>
<td colspan="11"> None Reported</td>
<td colspan="7"> Self Mutilization</td>
</tr>
<tr class="odd">
<td colspan="11"> Suicidal (assess lethality if present)</td>
<td colspan="6"> Intent</td>
<td> Plan</td>
</tr>
<tr class="even">
<td><strong>Aggressive</strong></td>
<td colspan="5"> None Reported</td>
<td colspan="13"> Aggressive (assess lethality of present)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="11"> Intent</td>
<td colspan="7"> Plan</td>
</tr>
<tr class="even">
<td colspan="19"><strong>PERCEPTION</strong></td>
</tr>
<tr class="odd">
<td rowspan="3"><strong>Hallucinations</strong></td>
<td colspan="6"> None Reported</td>
<td colspan="7"> Auditory</td>
<td colspan="5"> Visual</td>
</tr>
<tr class="even">
<td colspan="6"> Olfactory</td>
<td colspan="7"> Gustatory</td>
<td colspan="5"> Tactile</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td><strong>Other</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Illusions</td>
<td colspan="6"> Depersonalization</td>
<td colspan="2"> Derealization</td>
</tr>
<tr class="odd">
<td colspan="19"><strong>THOUGHT PROCESS</strong></td>
</tr>
<tr class="even">
<td colspan="2"> Logical</td>
<td colspan="7"> Goal Oriented</td>
<td colspan="6"> Circumstantial</td>
<td colspan="4"> Tangential</td>
</tr>
<tr class="odd">
<td colspan="2"> Loose</td>
<td colspan="7"> Rapid Thoughts</td>
<td colspan="6"> Incoherent</td>
<td colspan="4"> Concrete</td>
</tr>
<tr class="even">
<td colspan="2"> Blocked</td>
<td colspan="7"> Flight of Ideas</td>
<td colspan="6"> Perserverative</td>
<td colspan="4"> Derailment</td>
</tr>
<tr class="odd">
<td colspan="19">Describe:      </td>
</tr>
<tr class="even">
<td colspan="19"><strong>MOOD</strong></td>
</tr>
<tr class="odd">
<td colspan="3"> Euthymic</td>
<td colspan="10"> Depressed</td>
<td colspan="6"> Anxious</td>
</tr>
<tr class="even">
<td colspan="3"> Angry</td>
<td colspan="10"> Euphoric</td>
<td colspan="6"> Irritable</td>
</tr>
<tr class="odd">
<td colspan="19"><strong>AFFECT</strong></td>
</tr>
<tr class="even">
<td colspan="2"> Flat</td>
<td colspan="7"> Inappropriate</td>
<td colspan="6"> Labile</td>
<td colspan="4"> Blunted</td>
</tr>
<tr class="odd">
<td colspan="3"> Congruent with Mood</td>
<td colspan="10"> Full</td>
<td colspan="6"> Constricted</td>
</tr>
<tr class="even">
<td colspan="19"><strong>BEHAVIOR</strong></td>
</tr>
<tr class="odd">
<td colspan="3"> No behavior issues</td>
<td colspan="10"> Assaultive</td>
<td colspan="6"> Resistant</td>
</tr>
<tr class="even">
<td colspan="3"> Aggressive</td>
<td colspan="10"> Agitated</td>
<td colspan="6"> Hyperactive</td>
</tr>
<tr class="odd">
<td colspan="3"> Restless</td>
<td colspan="10"> Sleepy</td>
<td colspan="6"> Intrusive</td>
</tr>
<tr class="even">
<td colspan="19"><strong>MOVEMENT</strong></td>
</tr>
<tr class="odd">
<td colspan="2"> Akasthisia</td>
<td colspan="7"> Dystonia</td>
<td colspan="6"> Tardive Dyskinesia</td>
<td colspan="4"> Tics</td>
</tr>
<tr class="even">
<td colspan="19">Describe:      </td>
</tr>
<tr class="odd">
<td colspan="19"><strong>COGNITION</strong></td>
</tr>
<tr class="even">
<td rowspan="3"><strong>Impairment of:</strong></td>
<td colspan="8"> None Reported</td>
<td colspan="6"> Orientation</td>
<td colspan="4"> Memory</td>
</tr>
<tr class="odd">
<td colspan="8"> Attention/Concentration</td>
<td colspan="10"> Ability to Abstract</td>
</tr>
<tr class="even">
<td colspan="18">Describe:      </td>
</tr>
<tr class="odd">
<td><strong>Intelligence Estimate</strong></td>
<td colspan="4"> Mental Retardation</td>
<td colspan="6"> Borderline</td>
<td colspan="6"> Average</td>
<td colspan="2"> Above Average</td>
</tr>
<tr class="even">
<td colspan="5"><strong>IMPULSE CONTROL</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>INSIGHT</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
<tr class="even">
<td colspan="5"><strong>JUDGMENT</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
</tbody>
</table>

  ----------------- -------------- --------- ------------ -------------- --------------
  **RISK                                                                 
  ASSESSMENT**                                                           

  **Risk to Self**  Low            Medium                 High           Chronic

  **Risk to         Low            Medium                 High           Chronic
  Others**                                                               

  **Serious current                                                      
  risk of any of                                                         
  the following:                                                         
  (Immediate                                                             
  response                                                               
  needed)**                                                              

  **Abuse or Family                          **Abuse or                  
  Violence** Yes No                          Family                      
                                             Violence**                  
                                             Yes No                      

  **Psychotic or                                                         
  Severely                                                               
  Psychologically                                                        
  Disabled** Yes No                                                      

  **Is there a                               **Any other                 
  handgun in the                             weapons?**                  
  home?** Yes No                             Yes No                      

  **Plan:**                                                              

  **Safety Plan                                                          
  Reviewed** Yes No                                                      
  ----------------- -------------- --------- ------------ -------------- --------------

Diagnoses and Interpretive Summary

+--------+-------------------------------------------------------------+
| ####   |                                                             |
| ## Bio |                                                             |
| psycho |                                                             |
| social |                                                             |
|  formu |                                                             |
| lation |                                                             |
+--------+-------------------------------------------------------------+
| ####   |                                                             |
| ##  {# |                                                             |
| sectio |                                                             |
| n-183} |                                                             |
|        |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| ##     |                                                             |
| #### D |                                                             |
| SM IV- |                                                             |
| TR Pro |                                                             |
| vision |                                                             |
| al Dia |                                                             |
| gnoses |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| I**    |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| II**   |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| III**  |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| IV**   |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| V**    |                                                             |
+--------+-------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treatment Acceptance/Resistance                                     |
+-----------------------------------------------------------------------+
| **Client accepts problem?** No Yes Comment:                           |
+-----------------------------------------------------------------------+
| **Client recognizes need for treatment?** No Yes Comment:             |
+-----------------------------------------------------------------------+
| **Client minimizes or blames others?** No Yes Comment:                |
+-----------------------------------------------------------------------+
| **External motivation is primary?** No Yes Comment:                   |
+-----------------------------------------------------------------------+

# Preliminary Treatment Plan & Referrals 

+-----------------+-----------------+--------+-----+------------------+
| ####            |                 |        |     |                  |
| ## Preliminary  |                 |        |     |                  |
| Biopsychosocial |                 |        |     |                  |
|  Treatment Plan |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| **Biological:** |                 |        |     |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
| **P             |                 |        |     |                  |
| sychological:** |                 |        |     |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
| **Social/E      |                 |        |     |                  |
| nvironmental:** |                 |        |     |                  |
|                 |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| #               |                 |        |     |                  |
| ##### Referrals |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Psychiatrist    | Psychologist    |        |     | Spiritual        |
|                 |                 | M      |     | Counselor        |
|                 |                 | edical |     |                  |
|                 |                 | Pr     |     |                  |
|                 |                 | ovider |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Benefits        | Nutritionist    |        |     | Vocational       |
| Coordinator     |                 | Re     |     | Counselor        |
|                 |                 | habili |     |                  |
|                 |                 | tation |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Social Worker   | Community       |        |     |                  |
|                 | Agency:         |        | Oth |                  |
|                 |                 |        | er: |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+

Physical Fitness (Optional)

+-----------------------------------------------------------------------+
| ######  {#section-184}                                                |
|                                                                       |
| ###### Physical Activity (please sel                                  |
| ect one of the following based on activity level for the past month): |
|                                                                       |
| > Avoids walking or exertion, e.g. always uses elevator, drives       |
| > whenever possible instead of                                        |
| >                                                                     |
| > walking.                                                            |
| >                                                                     |
| > Walks for pleasure, routinely uses stairs, occasionally exercises   |
| > sufficiently to cause heavy                                         |
| >                                                                     |
| > breathing or perspiration.                                          |
| >                                                                     |
| > Participates regularly in recreation or work requiring **modest     |
| > physical activity** such as golf,                                   |
| >                                                                     |
| > horseback riding, calisthenics, gymnastics, table tennis, bowling,  |
| > weight lifting, and yard work.                                      |
| >                                                                     |
| > 10-60 minutes per week                                              |
| >                                                                     |
| > More than one hour per week                                         |
| >                                                                     |
| > Participates regularly in **heavy physical exercise,** such as      |
| > running, jogging, swimming, cycling,                                |
| >                                                                     |
| > rowing, skipping rope, running in place or engaging in vigorous     |
| > aerobic activity such as tennis,                                    |
| >                                                                     |
| > basketball or handball.                                             |
| >                                                                     |
| > Runs less than a mile a week or engages in other exercise for less  |
| > than 30 minutes                                                     |
| >                                                                     |
| > per week                                                            |
| >                                                                     |
| > Runs 1-5 miles per week or engages in other exercise for 30-60      |
| > minutes per week                                                    |
| >                                                                     |
| > Runs 5-10 miles per week or engages in other exercise for 1-3 hours |
| > per week                                                            |
| >                                                                     |
| > Runs more than 10 miles per week or engages in other exercise for   |
| > more than 3 hours                                                   |
| >                                                                     |
| > per week                                                            |
+-----------------------------------------------------------------------+