Family and Patient Assessment Worksheet

Assessment Form - Michael Goodman

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).

Patient Name
First Last
1. FAMILY HISTORY
Is your son adopted?
- Yes
- No
How old was your son when he was adopted?
Describe Family Relationship dynamics – Who does he lives with?
Any siblings?
- Yes
- No
TREATMENT BARRIERS
Has the Patient run away or has the patient attempted to run away?
What was the precipitating event that lead the client to treatment?
2. SELF HARM
Explain all incidents or indications that your child may have with self harm through actions such as cutting, banging head, hurting himself on purpose etc:
3. EDUCATION HISTORY
Any school discipline history?
Any learning disabilities?
4. SUICIDAL IDEATION
Explain all verbal expressions of wanting others to think he was suicidal
Has the Patient ever had feelings or thoughts that they don't want to live?
Has the Patient ever experienced suicidal ideation thoughts about harming themselves or wanting others to think that?
Has the Patient ever been hospitalized or treated for a suicide attempt or threat?
5. VIOLENCE RISK ASSESSMENT
Violent behaviors he has exhibited verbal or physical
Violent abuse with peers?
Violent abuse with parents/guardians or elder parents?
Violent behaviors of abuse in the home?
Violent abuse with a parent?
Violent abuse with a sibling/child?
6. EXPOSURE TO TRAUMA
Has your son ever been exposed to any form of trauma? (if yes, please explain in detail):
7. SEXUAL RISK ASSESSMENT
Explain any sexual history including partners, victim of abuse, Pornography use, and Child abuse where your son would be the perpetrator.
8. 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.):
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
Does your son take your medication as prescribed?
Are you aware of any mental health diagnosis given to you by a doctor or therapist? If so, what was the diagnosis?
MEDICAL ILLNESS/CONDITIONS FOR WHICH YOUR SON HAS BEEN TREATED
9. MEDICAL HISTORY OVERVIEW
How good are your son's sleeping habits?
How is your son's appetite?
How is your son had any recent significant weight loss/gain?
Did your son experience any prenatal events?
Are there any medical conditions to prevent your son from participating in the program?
PREVIOUS DOCTOR INFORMATION
Primary Physician Name Phone Number Specialty
PREVIOUS DOCTOR INFORMATION
Psychiatrist Name Phone Number Specialty
PREVIOUS DOCTOR INFORMATION
Prior Physician Name Phone Number Specialty
10. PSYCHIATRIC AND MENTAL HEALTH
PREVIOUS TREATMENT YOUR SON HAS BEEN IN
Dates of Treatment Name of Provider Provider Address Provider Phone Number Reason for Treatment/Diagnosis
Has anyone in your family experienced or been diagnosed with a mental illness or problem? (Whom, how related, and diagnosis)
11. SOCIO-ECONOMIC
Legal history including police involvement that did not result in charges
Parole/Probation? (Where and what custody level?)
Any pending charges?
Criminal Charges? (When, where, and what charges?)

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

Primary Physician Name	Phone Number	Specialty

Psychiatrist Name	Phone Number	Specialty

Assessment Form - Michael Goodman

1. FAMILY HISTORY

TREATMENT BARRIERS

2. SELF HARM

3. EDUCATION HISTORY

4. SUICIDAL IDEATION

5. VIOLENCE RISK ASSESSMENT

6. EXPOSURE TO TRAUMA

7. SEXUAL RISK ASSESSMENT

8. SUBSTANCE USE HISTORY

9. MEDICAL HISTORY OVERVIEW

10. PSYCHIATRIC AND MENTAL HEALTH

11. SOCIO-ECONOMIC