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Initial Evaluation

(Please complete prior to the first session)

Client Name:Date of birth:Age:Sex:Race:

Parent Figures in Home:Relationship to Client:

PSYCHOSOCIAL STRESSORS (if more than 1 year ago, indicate date of event)

high crime neighborhood single parent home parental neglect or abandonment

Overcrowded living situation divorce/remarriage of parents physical or sexual abuse (years:)

unsanitary/unsafe residence arrest in family: placement in foster care (years:)

frequent changes in residence frequent family arguments other:

MENTAL HEALTH STATUS (check all that are problematic)

no problems insight hallucinations clouded consciousness

orientation to person judgment delusionsstrange thought processes

orientation to place ability to reason suicidal ideation strange mannerisms

orientation to time attention span homicidal ideation perseveration

recent memory affect (anxious/depressed/fearful/angry/other:)

remote memory motor activity (lethargic/restless/other:)

EMOTIONAL/BEHAVIORAL SYMPTOMS

Physical aggression Tantrums/disruptive Toileting problems Depressed mood

Threatens/intimidates Argumentative Sleeping problems Anxious mood

Property destruction Noncompliant/defiant Eating problems Low self esteem

Lies/manipulates Provokes others Alcohol/drug use Suicide gestures/attempts

Steals/shopliftsBlames others Sexual acting out Somatic complaints

Breaks curfew Irritable/easily annoyed Swears/verbal abuse Obsessive/compulsive behavior

Runs away Angry/resentful Hyperactive/impulsive Tics/Stereotypy/Odd Movements

Truancy Spiteful/vindictive Self injury Other:

MENTAL HEALTH/BEHAVIORAL TREATMENT HISTORY

Previous treatment: Treating Agency Dates of Treatment Prior Diagnoses:

in-clinic therapy

in-home services DD: Autism MR (Level:) PDD None

medication therapy Familial Diagnoses:

crisis unit

inpatient/residential Previous meds:

none other : Current meds:

EDUCATION

School placement: Grade:Name of School:

regular education educable mentally handicapped varying exceptionalities

emotionally handicapped trainable mentally handicapped specific learning disabled

severely emotionally disturbed profoundly mentally handicapped other:

Interventions: none suspended homebound failing grades held back other:

LEGAL INVOLVEMENT

none charges pending on probation previous placement in detention

previous arrests doing community service charges dropped other:

PHYSICAL HISTORY

Medical problems: Sensory impairment: Ambulation difficulties: Developmental History:

none
seizure disorder

cerebral palsy

asthma/allergies

other:
none
vision impaired

hearing impaired

sensory defensive

other:
no impairment
walks with difficulty

uses crutches/walker

wheelchair bound

other:

no problems

pregnancy/delivery problems

in utero alcohol/drug use

failure to thrive

other:

Current medications, therapies, other medical info:

SOCIAL/ADAPTIVE FUNCTIONING

Appearance: Self care skills:
Social Difficulties:

neat & clean
unkempt

odorous

dirty
completely independent
verbal prompting needed

some physical prompting

much manual guidance
gang membership easily embarrassedinterrupts others
poor eye contact gets teased shows no remorse

poor manners socially rejected overbearing/bossy

crowd follower difficulty sharing brags/boasts conversation skills

shy/withdrawn conflicts with friends other:

Communication Repertoire:

full sentences limited verbal signing articulation problem echolalic other:

OTHER INFORMATION

PROVISIONAL DIAGNOSES (To be completed by clinician)

Axis I:DSM/ICD:

Axis II:DSM/ICD:

Axis III:Axis V:GAF:

Axis IV:

Justification of Primary Diagnosis:

Signature of person completing this form:

Signed: Date:

Psychosocial Written: Date:Location:/ Date:Location:

Primary Clinician Credentials Date Completed