Attachment E.pdf
PDF 6 MB Posted
- Attached to
- Adult and Older Adult System of Care Services
- Solicitation number
- RFSQ-BHS-FY23-0210
- Issued by
- Santa Clara County, San Diego City, California
About this file
This document is a Sample Integrated Behavioral Health Assessment Form for Category 2 Outpatient Services, designed for use in mental health and substance abuse outpatient programs. The form serves as a clinical intake and assessment instrument submitted on December 2, 2022, for an active client episode. The assessment captures comprehensive client information including identifying information, presenting problems, substance use history, current medications, medical conditions, and mental status examination findings. The form is structured to evaluate multiple dimensions including ASAM (American Society of Addiction Medicine) risk ratings across various assessment categories, with sections addressing appearance, motor function, behavior, consciousness, orientation, speech, affect, mood, thought processes, intellect, memory, insight, and judgment.
The assessment form includes extensive trauma and abuse screening across emotional, physical, and sexual categories, both historically and within the preceding 30 days, as well as childhood trauma and neglect assessment. Additional sections document relevant psychosocial history, treatment history, cultural factors, family situation, social relationships, education and vocational information, inter-agency involvement, legal issues, and identified strengths and protective factors. The form culminates in clinical impression documentation, DSM-5/ICD-10 diagnosis assignment, narrative summary, and level of care recommendations. Document routing and approval status tracking is included, with the form designated as final for submission through the established approval process. This assessment template establishes standardized documentation requirements for integrated behavioral health service delivery in outpatient settings.
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Text version
Episode 2: MH SMH OP -Adult xx/xx/xxxx - Active
Client: XXXXX, XXXXX (#xxxxxxxx) Submitted
12/02/2022 at 12:09 PM by clinician
Identifying Information_ Assessment Date:
Type of Assessment :
Program Type:
Identifying Information:
Presenting Problem :
Attachment E
Sample Integrated Behavioral Health Assessment Form for Cateogry 2: Outpatient Services
Client: XXXXX, XXXXX (#xxxxxxxx) Submitted 12/02/2022 at 12:09 PM by clinician
Draft/Fina I: Fina I
Substance Use Substance:
Age of First Use:
Route of Administration:
Stage of Change:
ASAM Dimensions Risk Rating·
Comments:
Attachment F
Submitted 12/02/2022 at 12:09 PM by clinician
Current Medications:
Cur~rent or relevant past rredical conditions :
PCP Clinic:
Risk Rating·
Comments.
Appearance:
Motor:
Behavior: 1
Consciousness:
Submitted 12/02/2022 at 12:09 PM by clinician
Orientation:
Time:
Speech:
Affect:
Mood:
Thought:
Intellect:
Memory:
Insight:
Judgment:
Has anyone ever abused you?:
Errotionally in your life? (Made you feel bad through harsh words):
Submitted 12/02/2022 at 12:09 PM by clinician
Ermtionally in the last 30 days?:
Physically in your life? (Caused you physical harm/violence towa · ds you?):
Physically in the last 30 days?.
Sexually in your life? (Forced sexual advance/ acts):
Sexually in the last 30 days?:
As a child in your life? (Severe beatings, sexual acts with someone 5 years older than you):
Neglected your basic needs in your life?:
Relevant psychosocia I history
Submitted 12/02/2022 at 12:09 PM by clinician
Trauma and other risk factors :
Risk Rating·
ASAM Dimensions Cont Stage of Change :
Comments:
Submitted 12/02/2022 at 12:09 PM by clinician
Risk Rating. 2
Treatment History :
If relevant, what triggers maintains, or lessens the client's mental health symptoms?:
Describe the client's longest period of time without using and what helped:
Submitted 12/02/2022 at 12:09 PM by clinician
Risk Rating:
Cultural Factors/Considerations :
Relevant family history and current situation :
Submitted 12/02/2022 at 12:09 PM by clinician
Social relationships :
Education/vocation information:
Inter-Agency Involvement/Legal Issues :
Strengths/Protective Factors :
Submitted 12/02/2022 at 12:09 PM by clinician
Risk Rating:
Clinical Imgression
DSM 5/ICD-10 Diaqnosis:
Submitted 12/02/2022 at 12:09 PM by clinician
Narrative Summary/Level of Care Recommendation:
Submitted 12/02/2022 at 12:09 PM by clinician
Document Routing_ Status: Fina I
Approvers:
File details come from the government source that posted it. Updated .