CWS REHABILITATION INITIAL ASSESSMENT State Form 54573 (1-11) FAMILY & SOCIAL SERVICES ADMINISTRATION RICHMOND STATE HOSPITAL GENERAL Client Name: (need full name at time of admission) Admission Date (month, day, year): Avatar Chart Number: Date of Assessment (month, day, year): Time of Assessment:  AM  PM Assessment Type:  Initial  Initial Reassessment  Annual  Annual Reassessment Assessing Clinician: Assessing Clinician 2: Supervising Clinician: Notification Comments: Draft / Pending Approval / Final:  Draft  Pending Approval  Final Primary Language: (Aliased in from PM side) Preferred Language:  Arabic  French  Japanese  Sign Language  Chinese  German  Other  Spanish  English  Italian  Russian  Unknown Interpreter Used:  No  Yes Language Comments: Informant Type:  Another provider  Family / Significant other  Legal Representative  Client  Gatekeeper  Records from previous admission  Current Assessments / Evaluations  Justice system  Other (specify) Informant Comments: (Identify specific re: source of information / informants - assessed - reliability, validity. Informant comments re: reason for admission or events leading up to admission, symptoms described / reported, etc.).
LEISURE Leisure Interest Survey Leisure Interest  Active games / Sports  Activities with peers  Arts and Crafts  Fitness / Health  Hobbies and Clubs  Music  Outdoor Activities  Quiet / Solitary activities  Spirituality  TV/Video games /Computers  Other (specify) _____________________ Leisure Comments: Do You Have a Special Interest or Talent? Do You Wish to Share This With Others?  No  Yes Special Interest Comments: What is Your Favorite Activity? How Do You Spend Your Free Time?  With others  By yourself  Depends on situation  Unknown What Activities Do You Do When You are By Yourself? Activity Comments: (Clinician assessment - include recommendations) How Do You Usually React in Group Situations?  Join in  Leave group  Listen for a while, then join in  Quiet and watch  Unknown  Other (specify) _____________________________ Group Situation Comments: 2
LEARNING / EDUCATION Highest Level of Education Completed: (If patient states otherwise, note difference in information in the comments field.)  1 year college completed  2 years college completed  3 years college completed  4 + years college completed  4 yrs college completed  Associate’s  Bachelor’s  Doctorate  GED  *(Grade 1-12) Indicate highest level ____ ______________________________________  Master’s  Never attended school  Pre-School / Kindergarten  Special Ed / Emotional handicap  Trade or Business college  Unknown Education Program Type:  Special education  Regular  Gifted  Other  Home schooled  Unknown Special Education Type:  Emotional disability  Learning disability  Other  Unknown DIPLOMA:  GED  High school  College  None  Other Education Comments: Are You Interested in Increasing Your Academic Skills or Working Toward Your GED?  No  Yes Academic Skills / GED Comments: Reading Ability: (Describe in comments how ability was assessed)  No  Yes  Limited Reading Ability Comments: (Use standardized paragraph and address accordingly.) 4
LEARNING / EDUCATION (continued) Writing Ability: (Describe in comments how ability was assessed)  No  Yes  Limited Writing Ability Comments: (Have client write name. Have client write sentence, ie “The weather today is…” Transpose client’s written statements into comment box. Indicate reason in inability.) Client’s Ability to Learn / Motivation / Client’s Participation Ability to Learn  No Obvious / Apparent impairments  Cognitive deficit  Unable to assess Motivation to Learn  Motivated  Unmotivated  Unable to assess Participation in Assessment Process  Good  Fair  Poor  Unable to participate Learn / Motivation / Participation Comments: (Described above responses in detail) Client’s Preferred Learning Style:  Classroom setting  Hearing information  Small group setting  Demonstration  Individual  Video  Hands-on  information  Other (specify) ________________________ Learning Style Comments: Allen Cognitive Level:  N/A  Total Score Allen Cognitive Level Score: Name of Test / Results: 5
VOCATIONAL Have You Worked in the Past?  No  Yes  None / NA  Unknown List Past Employment: Where Was Your Most Recent Job? What Type of Work Did You Do? How Long Were You There? Reason for Leaving: Employment Comments: Do You Have Your Social Security Card?  No  Yes Are You Interested in Working During Your Stay?  No  Yes Preferred Type of Work: Vocational Comments: WELLNESS Wellness Indicators Client Understands the Wellness Concept?  Good  Fair  Poor  Unknown Client Strives to be Physically Fit?  Good  Fair  Poor  Unknown Client Initiates and Continues Physical Activities?  Good  Fair  Poor  Unknown Client Complies With Diet?  Good  Fair  Poor  Unknown Client Practices Healthy Lifestyle?  Good  Fair  Poor  Unknown Client Participates in Fitness Activities?  Good  Fair  Poor  Unknown Client Ambulates without Difficulty?  Good  Fair  Poor  Unknown Use of Leisure Time:  Good  Fair  Poor  Unknown Wellness Comments: 6
WELLNESS (continued) Addictions Past History of Addictions:  No  Yes  Denies  Unknown Addiction Issues:  Alcohol  Gambling  Drugs  Sexual  Exercise  Tobacco  Food  Other (specify) ___________ Other Addiction Issues: Addiction Comments: What Activities Do You Associate with Your Addiction? What Activities Did You Have to Give Up Due to Your Addiction? What Leisure Activities Have You Learned to Do Without the Use of a Substance? COMMUNITY SKILLS Community Living Skills / Self-Care Skills Community Resources Utilized  Community Center  Mental   Health Clubs  Movie Theaters  Support Groups  Library  Parks and Recreation  Other (specify) ______________  Malls  Restaurants Community Resources Comments: Community Living Needs:  Clothing care / Selection  Money management  Safety  Time management  Grooming / Hygiene  Nutritional / Meal planning  Shopping  Transportation  Home maintenance / Cleaning  Resource utilization  Survival skills  Other (specify) ________________________ Community Living Comments: 7
COMMUNITY SKILLS (continued) Social Functioning:  Difficulty controlling emotions  Difficulty interpreting others feelings  Expresses feelings effectively  Good communication skills  Intrusive  Lacks self esteem or self confidence  Outgoing  Self absorbed w/little regard for others  Talks excessively  Other (specify) _____________________________________________  Difficulty expressing feelings  Draws unnecessary attention to self  Expresses gratitude / Appreciation  Impolite / Disrespectful  Lack of personal boundaries  Minimal effective communication skills  Polite / Respectful  Self confident / Self esteem  Withdrawn Social Functioning Comments: Has Client Ever Volunteered?  No  Yes Volunteer Activities Comments: INTERVIEW OBSERVATIONS Appearance:  Appears older than stated age  Clean  Excessive / Inappropriate make-up  Poor grooming  Appears stated age  Clothing inappropriate to season  Malodorous  Other (specify) _____________________  Appears younger than stated age  Disheveled  Neat Appearance Comments: Interview Behavior:  Avoidant  Hyperactive  Mute  Resistant  Other (specify) ____________  Cooperative  Hypervigilant  Oppositional  Self-injurious  Defiant  Impulsive  Pacing  Verbally aggressive  Destructive  Intrusive  Physically aggressive  Withdrawn Interview Behavior Comments: 8
STRENGTHS / NEEDS and RECOMMENDATIONS (continued) Strengths Assessed Strengths Assessed  Adaptability  Education / Intelligence  Good social skills  Hopeful / Optimistic  Motivation  Survival skills optimistic  Other (specify) ________________________  Capacity of control  Family / Community support  High self esteem  Independent self care skills  Resourceful  Use of hobbies / Leisure activities  Cooperative / Follows directions  Good communication skills  Honesty  Insight  Source of income  Work skills Needs Needs Assessed  Addiction education / Support  Lack of family / Community support  Limited education  Low self esteem  Poor coping skills  Poor independent living skills  Other (specify) ________________________  Anger issues  Lack of insight  Limited leisure interest  Non-compliance  Poor decision making  Poor self-care  Easily frustrated  Lack of interest  Loss of hope / Pessimistic  Poor concentration  Poor health  Poor social skills Strengths / Needs Comments: 10