Comprehensive Assessment Toc "ison aeYL Children' a Agcs In home 1, A 5 mm. 68w" vamg Dpls) Suppon 151m Suppon sober" (for CD ms)'Y Milimrynismry Km Branch. Yum . . memod orcommumeauon forducussing l/R A Culmra ellglous/ spmmal Beliefs. "when Em" mm" - th which gender do you war. which gendcrarc on coulfonahl: roommw [3 ommlicnl Cm Comm Inm Informant: Prcku: chords Vitals date and! A CIWA 37-- HAL: UTOX COWS Pmipiming Evenl Ind Significnnl Hillary: (Briefly descnbe m: cvenls mm occurred |he last 72 hours which an assessmenl Ioday) Dascribc response below in paliem's own wards. (WHY Hr fi'r cam.-- in fir 35x +9 ms '3 difBuk mad-s be.ng was a: - 1 of Presenulinn: Comh hly Up Saw Clinical Presentation/ Mimic Anxizty Mood . A Diminished Raclng 3/ VGAD .54 Annedama lmpulsivily 7 Hopelessrress lmmbiluy can u} Euphorla i Helplessness Spending Spree: nfgulil llyper stxunlny 1 Relaxdulloll Pressured 7 Agilalinn 2/ Sad Mood lor fl Spells energy Hallucin 'o Commlud l:l Audilory El Visual mule l:l Describe: Plunnil l:l Hyper-rellginlli Grandinsily i ldulion Describe: \a D'Lwrganizzd Dacnhc: Bell-vial or Speech Somatic "0 "mm" llilig asleep El Energy: 1 1 1 Weigm Change: Sleep: \Zhn 1g", "wk, DNighmarL-s [liming Elbummg' Dpickiug Ehudhullgv when Lasl occurrence _5 I In of Eating Disnrden: lane Binge Eating Anolexia/Reslricnng Bulimia: Binge/Purge Active currently: Ya! 'No Last Active Episode Comments: MHICD Impacl on Day Living . 5w." Yes No .1 cull 6 MIL DSujpension/Expulsinll ark/school fiLalelo or chunl DPoolgradcs Dereriumiorr in hygien: and/av gmamillg no 04M 12 Socill isoluing or dilliculry 5W 5M '94 Problems wim abilily lo parem Mil/A nol a pawn xx" my abov: I: pllienl gnvely disabled (unlble can for sell? N) Yes. as evrdm 3 (Raw Adull Child/Adolescent Behaviors Yes Nu Vt: No Yes No Increascd Elm DPas| "My DCurrcm Energy Ammals DCumnl .. 7 ma Dl'au . DPast 1 5mm" DCunem DCuncm Dcuncnl I 4; Use n( Dam [Ivan Elm-mm Weapons DCum'nl DCunem 1 Assaulnve DPN Elms! '"w'v'mm DCun'cm Bchavlur Dcuncm nl Pvupcny DCumm Adolescent Patient Additional Informatio School: Hume/Numb": 7 Grade: Regular Ed: yes nu Aspergcr's [3 GED Auusm Home schuol oumi Precipitants and Stressors Cuneemsrelaledm: Ves Na Ducribe Fr:glancy/ledbmh/Adopnon Financcs aaeg 5 H1, dynamo! avg", bF svgnifmamomcrs pl" ,5 fl hfiaddl Recent dead! af low: on: REcem manage or divorce 1 Race Gender Sexual Oriemauon 3 Cuhuml ldennty Socileedia A Olhcr 4 FinancinISlmus/Sourceoflntome gamma DDisabiluy DDepcndenlanfamlly Cummenb' Actowrham' Legll History(CnrrenI and ram": pas! hismry) None EICumm [3 Past thnfion 1] Parole 1101 for Probation! Parole omccrEI may Chargcs' Inpatient Tremment History: Abus: El Pl, dcnics history of Inpl Rum" [nrAd nous A Outpatient Treatment m. ufUmpl Ix Desctibe an 0mm Mmcu xx hisiary: Mm Current Risk to Self Suitkl: Risk 3 1 I Ilow is your desire l. a Mnderalc llow simng IS um>> lo diL Weak Do you have more reason: In llv: or the" lo . When was [he lusl you had ihnughi: lusl \vulnn in l:l vunnl Mu Mel-m: on mun; 7 12 hours 7 Eng)" llu oflen you abnln sum-1:" Always unruly llow long do your sulculul lhoughis mm M) End "7le Do you hav: a plan on lo how you would kill yourscm mos No Describe vim"; How are you in nu upon your thoughts or Mast . suicide? Defimlely We" wen i Have you :vrr anempied suicide in H1: pnsF' My", it ornlumpu. Dams) Scaring: Add up in: nunllm olmnunsu In each column Mul|lply "mm by m: column value mm lolul all (9 2 Grand Tomi: Suicide Scare: El 0-8 Low M47 MODERATE BDI Score: 13-17 HIGH "mellow 5H4 01> <20 vim i) away; my Additional Risk Factors "0 llulory afsuiciduuempls .n friends in family "who," llislary afsuicide in Friends nr family ny ulloln F-mily Menu] Hum: hinury, [3 Pl, Denies Dn you have access to weapons? I: Yes We Lethal Medication Kw; Nu ,7 Family ham Yes Kilo Nlme of plrson wring: Rn Vim/lay Accuracy of Reports and History of Risk [5 "mm any cvuluncc avallablc or tullcum |hn| [he pnucnl nr alhurs lnny he s! cum'm or assaulhvc belluumrs V0: ll'ycs. me and cuucunn A 7- fl, 7 7 Suicide Prutcctivc Factors u. liulurc rucuml Dmnnus rum my Mum>> lmulmuul supnun groups) 1] Absence nl'nlnn. mean: [1 (mod impulse cununl El wnlu range ul'ul'l'ecuvc El bellch Nu hisxary abuse Has childmn u: dc ndun flaw: llislory dulng Cr 1] Does nul View sllunllon :ls ur incscapablc used by nalicnu u. dangcwus if 7 i None currenlly nl pn/ ms alcohol and drug use Alcohol/Drug Abuse ln the pun: I2 mum/n Subsunu/ Typ: Dumlion of Lasl us: An" uscd Ag: at (beer, liquor, "Wm" Us: lauu 1" us: A 1' A Expluin pulicurs pallet-n alum before maps: lnul supparls a Mm A Audit-C - lluw nflen da you hm a drll'lk comm flux-rm) El Muulnly or less (I) :4 monlh 2-: "me: week (3) 4 armor: Ilmesa wk (4) (Se/ac! one respumz) How many drinks conlalning alcohol do ynu have an day when you are (Select one ur2(fl) Eljuml) EISnrelZ) D7lavu) Normal-cu) Huw 00:" da you IIth or more drinks un one occamm (Sn/ea one rEJpaleel F/Neverfln l:l Lesslhan ll) :1 (2) El Weekly (3) El Dally uralmusl uluily (4) Tulal Sen Mun. In um on mum: :wxuku'd Mum uu huudmu ulcunul m4: numnm lu mun,- mu; ur um p. liltinle mun": mum nwmu mum. on mun A Fm ly substance abuse hislary r'l PI Pnlicnl Label ulsobric ,thfl 7 i 7 (mun Pm Elna V0 Yes Current related In withdrawal (dwck all mm mm acme. El El uan Immnn Cranngs El El nun-rm [1 Black um; Aggrculon'Asmuh [3 Poor Appemu mm", I'amnuln Runny new Vawnmg Em Pam 10ml Pam Tearing DIher 7 7 77 fl 7 Pancnl rcpm-u cuI-rcnl as Mm! Modem: 5mm ,urcs" El Yes No In ofDT'i" Yes Nu nl'macknummc mummch 13 V23 No Dal: Selzurc' E, i scare: cows scam Completed by 717 1 Medical Screening [IMPI mics all arrest l: pm Shonness unmam Paumyabsum rtparls on Ms medical dzamncc Lass seizured/o dclox unk rain Assessment Kn aunts pm Pain ra ng scale Pam Rallng' anaunn' Descriplian if 7 M71 denies mama] Issu:s Femals. Pregnanl' yes mu pmgnancyv yesfi nu Refemb gwcu Allergies (fund/met" Cumm Mediulinns QHS=ucry an), lwlce my no: (hm: dam PRN: as nccded .1 Problems 1mm: Nun: at Medlcnian Dmin Dons E]am Emu Medicnians within Ia" year: mm Fall Risk Facturs Nune Unsleudv On" [3 Over age in [j MnlhI-llu Subslanccs dl .rlls [j 7 7 7 77 7 Trauma Hislory 7 Ah ls 777when abuse occur when: abmc ntcur (udrlress. euy, slam. cuumy) 7 7 7 (cl/ems rr. be mpuncdl 7 Sexull: By whom (Name und :0 pl -7 Age/D01! Dumrrun/Number Occurrence WM: happened (evenrs (o h: rcpurldd) if 7 7 7 AbEercr-dn fieTnJ 7 When dul um}: occur 777, A Domestic violence Cnnfirms Denies lrcunfirrns. 'eserlbe when and b1 whom Ar: uu erranl serery erhenre 7 being>>. small /elunhonn|ly ebused'l Are an a whreh it)" have been hurl or Huve you ever been .kielred. or punched by somenne elose re yml" ll ofumcs in pas! car. A A Sexual Viclimization Risk Risk to Others Sexual Victimizzlian Yes No Factors may compromise residenl's self-defense? n. Level offimcllaning (developmenrelly challenged, mentally relsrded) b. Physical status/medical conditions lhal may compromise resldenl's self-defense, Ages ECT, Medically Compromlsed. Sedation, etc. Prcviuus hlslerml sexual victimizalion? Sexually behale 2 ls thisfllicm hr risk for sexual victimization? Cl sexunlly Aggressive Behavior: Indicalursfor paliems al risMr sexually aggressive behavior: Yes 3 Hlslory ersexunl abuse perperrslion? sexual hislury? Level alps chosiswilh LI A Is palicnl in risk lor sexually aggressive behaviur? CF If yes, [a any uflhe abovc. describe: (1)4wa urn/m 7 Hoot 11-] Risk Flclun: Yes Nui Is the": idealinn. plan, ot_th cots In the past 6 munlhs" lx i Comm hummdal tdcotton, plan. or means" Command I Pamnuld Identiun I Is [here tu to any or the above lIrC ves. (Ilcn hum rot a NM Specific! targets. Cumpm: duly to Warn mronnauon l'nlicc Contact Dale/um i _7 Elopement Risk Factors: [1 Nom: [1 Hx ofclopement Involuntary Status lmpulslvuy El Otmr Patient Strength El supporl system Sening goals {Access to Huttsing Tx [1 Open (0 Tx leing El Compliance outpattent treatment allianc: [1 Community Involvement Smady Employment School Engagement [1 Mental Status Exam um l:l AMOPRKATE El momma/tom mawuct l:l MALomRous APPEARANCE cutmcr El DISIIEVELED l:l UNCLEAN l:l l:l ulumta [1 mm a DRAMATIC xmvr. SPEECH l:l SLOW :Nous SKCAI l:l MUMBUNG NFUTIAL [1 5mm l:l unmassn) Watt 3 MOOD UKNDIWERENY l:l l:l Elmo" DSUSHCVUUS 7, THour-m HOOD mcotmtum moutatn vltocpss/ Mom) AFFECT l:l Noun-mun l:l ammo l:l ExAcoEn/tmn :l El rmrut. l:l want l:l EUIIWMIC rm l:l HLUNYED l:l :wsmmu l:l IRMYMILE tnmt: INAFVROWIME ORIENTATIDN [flaunt MACE stT/mcn Mm momma DWW l' CONCENTRATION l:l Ath'l l:l mnmseo El a l:l RACING mcuum mocess Axiom/mam l:l cl mmuotm 'l MEMORV (flan DIMPAIIED 7,7 a GOOD MAM t: um Patient Label I 4) <