Youth Pre-Evaluation Screening Date: Time In: Time Out: Interview Location: Individuals Present: Interpretative Aids/Assisted Devices: Pending Felony Charges: ☐ Yes ☐ No Case Number: CMHC Region: In the court of County Voluntary CSU Admission Sought : ☐ Yes ☐ No Mobile Crisis Involvement : ☐ Yes ☐ No Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical records and interviews with family member and the affiant requesting commitment will be included in this report. Respondent Demographics Name: DOB: Age: Gender: Race: Social Sec #: Medicaid #: Medicare#: Home Address: Phone Number: Does the respondent have a legal guardian or conservator: ☐ Yes ☐ No Guardian/Conservator Contact Information Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Affiant Demographics Affiant Name: Relation of Respondent: Number: Home Address: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Respondent Psychosocial Information Current Living: Current Grade in School: Name of School: History of IEP or 504C: ☐ Yes ☐ No Date of most recent IEP or 504C: Juvenile Justice Involvement: ☐ Yes ☐ No Describe Source of Information: ☐Respondent ☐Affiant Review ☐Other Psychiatric History Current Psychotropic Medications: Dosage & Date/Time Last Taken: Is the medication helpful or problematic: Psychiatric Hospitalizations: Outpatient Treatments: Locations/Dates: Psychological Testing: Provider/Dates: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Medical Status & Treatment History Current Medications (not listed above): Dosage & Date/Time Last Taken: Is the medication helpful or problematic: . Medication Allergies: Currently Under Physician Care For: Physician’s Name: Conditions Treated In The Past: Provider/Dates: Medical Hospitalization History: Physical Disabilities: Current Communicable Diseases: ☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis) ☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other Currently Pregnant: ☐ Yes ☐ No Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Developmental Disability Pregnancy/Delivery Complications: ☐ Yes ☐ No Describe: Met Developmental Milestones On Time: Walked ☐ Talked ☐ Crawled ☐ Toilet Trained ☐ Feeding ☐ If no, describe: History of Special Education Ruling: ☐ Yes ☐ No If yes, describe: Documented IQ below 70: ☐ Yes ☐ No If yes, describe: Documented sub-average intellectual functioning before age 18: ☐ Yes ☐ No If yes, describe: Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe: Specific Observed Adaptive Functioning Deficits: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Oriented to Date: Time: Place: *Cue for three words (provide words) President: Mental State Exam Counting Response: Word Recall: Completed Written Command: ☐ Yes ☐ No If no, describe: What do you understand the reason for our meeting today to be? Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Psychiatric Symptoms Past Month Respondent( R ) Informant(I) Mood Symptoms R I Mood Symptoms R I Behavioral Symptoms R I ☐ Depressed mood/Appears Sad ☐ ☐ ☐ Dizzy ☐ ☐ ☐Attempts to “ Others ☐ ☐ ☐ Enjoys Very Little ☐ ☐ ☐ Shaking/Trembling ☐ ☐ ☐ Defies Requests ☐ ☐ ☐ Cries Frequently ☐ ☐ ☐Excessive Sweating ☐ ☐ ☐ Angry & Resentful ☐ ☐ ☐ Decrease in Appetite ☐ ☐ ☐ Shortness of Breath ☐ ☐ ☐ Sullen ☐ ☐ ☐ Increase in Appetite ☐ ☐ ☐ Tingling in Hands or Feet ☐ ☐ ☐ Irritable ☐ ☐
Interpersonal Lack of privacy ☐ Being approached by men or women ☐Arguments ☐People Yelling ☐ Confined spaces ☐Being touched ☐ People too close with Family ☐ Being stared at ☐ Being ignored ☐Feeling pressured ☐ Being ordered to do something ☐ Being approached by women ☐ Being Teased/picked on ☐ Tall or large people ☐ Smells ☐People focusing on my symptoms Other Triggers ☐ Taste ☐ Time of Day ☐sounds ☐ Sights ☐ Sensations/textures ☐ Wringing ☐ Heart Pounding ☐ Shortness of Breath ☐ Breathing Hard ☐Wringing hands Warning Signs of ☐ Clenching teeth ☐ Flushed/red face ☐ Crying ☐Clenching fists Emotional ☐Bouncing legs ☐Singing ☐Can’t sit ☐Cursing/swearing ☐ Sweating ☐ Rocking ☐Pacing ☐Giggling Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Suicide Assessment Prior Attempts: Friend or Family Member Completed Suicide: Approximate Date: Approximate Date: Method of attempt: Method of suicide: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Behaviors Exhibited by Respondent History or Present Danger to Self ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below) ☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death ☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation ☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others ☐ Other Describe: Violence Risk Assessment Current thoughts about harming another person Yes ☐ No If Yes, whom: If yes, how long have you had these thoughts If yes, specific plan: Access to means to carry out plan: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Violence Risk Factors Present Present Unknown Present Unknown ☐ ☐ Male Gender ☐ ☐ Substance Abuse ☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx ☐ ☐ offense history ☐ ☐ Anger ☐ ☐ Psychopathy (PCL:SV>12) ☐ ☐ Antisocial Personality Diagnosis ☐ ☐ Violent Fantasies Frequency, type, recency ☐ ☐ Previous violence against other people Frequency, severity, type ☐ ☐ Childhood physical abuse Frequency, severity Source of Information: ☐Respondent ☐Affiant Review ☐Other
Substance Use Do you currently use? Past Use Amount Frequency Age of Initiation Caffeine Nicotine Alcohol Marijuana Opioids Amphetamines Hallucinogenic Prescription Medication Over the counter medication History of legal charges related to substance use? ☐ Yes ☐ No Describe: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Describe: Behavioral Observations Activity Diminished Normal Excessive Unusual ☐ Frozen ☐ Purposeful ☐ Restless ☐ ☐ Catatonic ☐ Coordinated ☐ Squirming ☐ Almost motionless ☐ Other ☐ Fidgety ☐ Little animation ☐ Constant movement ☐ Psychomotor retardation ☐ Hyperactive ☐ Slowed reaction time ☐ Other ☐ Other Speech Slowed Normal Pressured Verbose Unusual ☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐ ☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded ☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop ☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons ☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ☐ Single word answers ☐Smooth ☐ Other verbal ☐ Other ☐ Other ☐Other