Family and Patient Assessment Worksheet

Assessment Form

Please complete this form with detailed answers. Your answers will be used to assist the therapist in developing an accurate treatment plan.

Your detailed answers will also be used in obtaining the best possible coverage from your insurance provider if such treatment is covered under your medical health insurance policy.

Failure to provide detailed answers will only hurt the development of an accurate treatment plan and delay or prevent the payment of your health insurance benefits (if any).

PREVIOUS TREATMENT
Dates of Treatment Name of Provider Provider Address Provider Phone Number Reason for Treatment/Diagnosis
PREVIOUS DOCTOR INFORMATION
Name Physician Type Phone Number Specialty
LIST EACH MEDICATION PREVIOUSLY PRESCRIBED
Name of Medication Dosage Frequency Taken Time Period Medication Was Taken Reason for Medication
CURRENT MEDICATION
Name of Medication Dosage Frequency Taken When was Medication Prescribed Reason for Medication
MEDICAL ILLNESS/CONDITIONS FOR WHICH YOUR SON HAS BEEN TREATED
1. PARTICIPATING CRISIS
Why are you seeking treatment at this time? Please list all external or internal factors
2. FAMILY HISTORY
Is your son adopted?
- Yes
- No
How old was your son when he was adopted?
Relationship dynamics – Who does he lives with?
Any siblings?
- Yes
- No
Childhood Family Experience relevant to current issues:
Issues of Conflict and support in the home:
3. CHILD DEVELOPMENT
Critical Prenatal and Perinatal Events: (For example has there been any prenatal exposure to drugs or alcohol)
Did the Biological Mother have a known history of Mental Health Sickness/Problems?
Psychological History (Temperament):
Intellectual/Academic History including discipline history:
4. SUBSTANCE USE HISTORY
Child’s personal substance use history:
Current use pattern, substances used, frequency and amount of use (please include when your son started using and explain the pattern of used that evolved up to the time of intake at Liahona Academy, including first drug use, new drugs used, how much was being taken and how often):
Did your Son sell drugs in addition to using?
- Yes
- No
Family Use History (Parental, Siblings, Grandparents etc.):
5. SOCIO-ECONOMIC
Legal history including police involvement that did not result in charges:
Sexual History including porn use:
6. PSYCHIATRIC AND MENTAL HEALTH
Previous treatment setting and/or therapeutic settings (names, address, length of stay & phone numbers):
Interventions and response: (interventions used during treatment and response to those interventions):
Previous diagnosis received (not mentioned above):
Response to Previous Treatment (not mentioned above):
7. MEDICAL HISTORY
Medication History including when it was prescribed, by whom, dose, and son’s response to the medication:
Relevant Family Medical History:
8. VIOLENT BEHAVIORS HE HAS EXHIBITED VERBAL OR PHYSICAL
9. SUICIDAL IDEATION
Explain all verbal expressions of wanting to die or wanting to cause self-harm:
Explain all explicit attempts of suicide (please include any examples of self-harm):
10. EXPOSURE TO TRAUMA
Has your son every been exposed to any form of trauma? (if yes, please explain in detail):

Dates of Treatment	Name of Provider	Provider Address	Provider Phone Number	Reason for Treatment/Diagnosis

Name	Physician Type	Phone Number	Specialty

Name of Medication	Dosage	Frequency Taken	Time Period Medication Was Taken	Reason for Medication

Name of Medication	Dosage	Frequency Taken	When was Medication Prescribed	Reason for Medication

Assessment Form

1. PARTICIPATING CRISIS

2. FAMILY HISTORY

3. CHILD DEVELOPMENT

4. SUBSTANCE USE HISTORY

5. SOCIO-ECONOMIC

6. PSYCHIATRIC AND MENTAL HEALTH

7. MEDICAL HISTORY

8. VIOLENT BEHAVIORS HE HAS EXHIBITED VERBAL OR PHYSICAL

9. SUICIDAL IDEATION

10. EXPOSURE TO TRAUMA