Body Movement: WNL Accelerated Slowed Peculiar Restless Agitated Behavior: WNL Cooperative Uncooperative Overly Compliant Withdrawn Sleepy Silly Avoidant/Guarded/ Suspicious Nervous/ Anxious Preoccupied Restless Demanding Controlling Unable to perceive pleasure Provocative Hyperactive Impulsive Agitated Angry Assaultive Aggressive Compulsive Relaxed Speech: WNL Mute Over-talkative Slowed Slurred Stammering Pressured Loud Soft Clear Repetitive Emotional (in person’s words): WNL Not feeling anything Irritated Happy Angry Hostile Depressed, sad Anxious Afraid, Apprehensive Emotional State- Affect WNL Constricted Changeable Inappropriate Flat Full Blunted, unvarying Facial Expression WNL Anxiety, fear, apprehension Sadness, depression Anger, hostility, irritability Elated Expressionless Inappropriate Unvarying Perception: WNL Hallucinations- Tactile Auditory Visual Olfactory Command ** Thought Content: WNL Delusions- None Reported Grandiose Persecutory Somatic Illogical Chaotic Religious Other Content- Preoccupied Obsessional Guarded Phobic Suspicious Guilty Thought broadcasting Thought insertion Ideas of reference Thought Process: WNL Incoherent Decreased thought flow Blocked Flight of ideas Loose Racing Chaotic Concrete Tangential Intellectual Functioning: WNL Lessened fund of common knowledge Impaired concentration Impaired calculation ability Intelligence Estimate - Develop. Disabled Borderline Average Above average No formal testing Orientation: WNL Disoriented to: Time Place Person Memory: WNL Impaired: Immediate recall Recent memory Remote memory Short Attention Span Insight: WNL Difficulty acknowledging presence of psychological problems Mostly blames other for problems Thinks he/she has no problems Judgment: WNL Impaired Ability to Make Reasonable Decisions: Mild Moderate Severe** Past Attempts to Harm Self or Others: None Reported Self** Others** Self Abuse Thoughts: None reported Cutting** Burning** Other: Suicidal Thoughts: None reported Passive SI** Intent** Plan** Means** Aggressive Thoughts: None reported Intent** Plan** Means** Comments: Person’s Name (First MI Last): Record #: Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors) Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions) Mood
Current Needs Selected Above as Evidenced By: Employment/ Education/ Finances CN = Current Need Area PD = Person Desires Change Now CN PD CN PD CN PD Education Employment/ Volunteer Activities Meaningful Activities Financial/Benefits (include VA benefits) Current Needs Selected Above as Evidenced By: Addictive Behavior and Substance Use CN = Current Need Area PD = Person Desires Change Now CN PD CN PD Substance Use/ Addiction (Tobacco, illicit & licit drugs) Other Addictive Behaviors (food, gambling, exercise, sex etc.) Current Needs Selected Above as Evidenced By: Person’s Name (First MI Last): Record #: Mental Health/ Illness Management-Behavior Management CN = Current Need Area PD = Person Desires Change Now CN PD CN PD CN PD Anxiety Dissociation Lack of Assertiveness Anger/ Aggression Disturbed Reality (Hallucinations) Swings Antisocial Behaviors Disturbed Reality (Delusions) Obsessions Coping/ Symptom Management Gender Identity Oppositional Behaviors Cognitive Problems Grief/Bereavement Somatic Problems Compulsive Behavior Hyperactivity/Hypomania Stress Management Depression/Sadness Impulsivity Trauma Other:
Person’s Service Preferences, Level of Care/Indicated Services Recommendation: Person Served/Guardian/Family Response To Recommendations: Person’s Signature (Optional, if clinically appropriate) Date: Parent/Guardian Signature (If appropriate): Date: Clinician/Provider - Print Name/Credential: Date: Supervisor - Name/Credential (if needed): Date: Clinician/Provider Signature: Date: Supervisor Signature (if needed): Date: Psychiatrist/MD/DO (If required): Date: Next Appointment: Date: Time: am pm