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Date of Assessment:
What are the presenting problems? Severity, Frequency, and Duration of chief
complaint? Discuss recurring symptoms/behaviors, functional risks? Onset of
problems? (Include relevant psychological and social conditions affecting psychiatric status)
Why seeking treatment now (any early indications or significant behaviors that could be disruptive/risk to
community/family/school, significant)?
BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. REVJUL 2008
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Consumer Name: CID#
Psychosocial
Stressors/Events:
Recent Death Relapse
Physical Abuse School
Sexual Abuse Problems
Emotional Custody Issues
Abuse Placement
Recent Issues
Hospitalization
Legal Issues
□Prior or Current Psychotherapy or Psychiatric Treatment? (Include when, why, with whom, length
and type of treatment, was treatment considered successful, and why was it discontinued)?
□History of self-injury/self-mutilation??
Medical History
□Name of Current Physician/ or Practice Name:
□Date of last physical?
□Are immunizations up to date? Yes No
□Passed Vision Screen? Yes No
□Passed Hearing Screen? Yes No
□Results of last dental exam?
□Any Medical Condition (s)? Yes No
If yes, what effect medical condition has on consumer’s level of physical functioning and mental
health?
□Allergies:
□Current medication(s)?
□Any significant Family Medical History?
BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. REVJUL 2008
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Family History
Current Relationship: (children & adolescents inquire about their parents, if applicable)
Married Domestic Partner Separated Single None
Discuss length, history, status of relationship, supportive, problems:
Educational History
1. Last grade level completed:
2. School setting? Type of Classroom Placement:
3. Number and grade levels of retentions:
4. Is the student support team (SST) currently serving the child? Yes No
5. Does the child have an IEP? Yes No
6. Rate the child’s attendance in school and also give the number of days absent in the last 30 days
(request and review the school records if needed).
Other Comments:
BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008
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Functional Impairments
(Estimate the effect behavioral problems or emotional distress has on the following):
Currently By hx
Currently By hx
Currently By hx
Currently By hx
□ Last Use? (What drug did you experience recently, how long ago, how much)
□ Have received prior treatment for this issue (who, when, where, outcome):
BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008
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Criminal/Legal History
□ On Probation? If yes, give details and obtain name of PO and a contact number:
□ Other Status
AXIS I: (Primary)
AXIS I: (Secondary)
AXIS II:
AXIS III:
AXIS IV:
AXIS V: Current GAF _______ Highest GAF in the Past Year ______
1. 3.
2. 4.
INTERGRATIVE SUMMARY
BH1501(a) Behavioral Health Assessment © Jireh Counseling And Consulting Services, Inc. RevAUG 2008
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