Case-Based Mental Health Assessment and Risk Management Plan

ASSESSMENT DETAILS

Clinician:Place:Program:

Date:

Time:

Precipitants

History of current episode & treatment

Change in behaviour Signs and symptoms:

Hallucinations

Abnormal Ideation

Preoccupations

Suicidal Ideation

Aggressive

Homicidal thoughts

Anxiety states

Mood disturbance

Sleep

Appetite

Substance abuse

Other disability IDS/Physical Demographics

Major Illnesses Surgical Interventions Current medical health PRESENTING PROBLEMS (Clients perception of problem)

COLLATERAL HISTORY

MEDICAL HISTORY/CURRENT MEDICATIONS

PSYCHIATRIC HISTORY / MHA STATUS

FAMILY HISTORY (Includes family history of mental illness, quality of relationships, current family issues)

GENOGRAM

Genogram Key

Male Female Unknown Married Defacto Separated Divorce Adoption Death Milestones School

Academic performance Social development Friends at school Childhood interests Hobbies

Current support network Psychosexual development Significant intimate relationships

Cultural Issues Reason for migration

Connection with community Recreational interests

Capacity for independent living PERSONAL HISTORY

Appearance

Physical

Dress

Grooming Personal hygiene

Behaviour

Guarded

Suspicious

Distracted

Psychomotor retardation

Compulsions

Panic attacks

Catatonic behavior

Eye contact

Mannerisms

Degree cooperation

Rapport

Gait

Speech

Rate, volume, tone

Coherence

Spontaneity

Repetition

Thought form

Flight of ideas

Loosening of association

Circumstantiality

Confabulation

Incoherence

Poverty of thought

Neologisms

Perserverations

Echolalia

Clanging MENTAL STATUS EXAMINATION

Thought content

Overvalued ideas

Illogical thinking

Ideas of reference

Paranoid ideation

Thought withdrawal

Thought insertion

Delusions

Anhedonia

Homicidal/suicidal

Disorders of perception

Illusions

Hallucinations

Emotional state Cognitive & biologival Judgment

Level of insight DRUG ALCOHOL SCREENING

Substance Past Use Current Use Quantity Frequency Route Age First Use Last Used Depressants Benzodiazapines Codeine, morph Cannabis Methadone Heroin Stimulants Amphetamine (speed, ice) Ecstasy Cocaine Hallucinogens LSD

Mushrooms Inhalants GHB Alcohol Spirits Beer Wine PREVIOUS WITHDRAWAL ATTEMPTS/REHABILITATION

INTERACTION BETWEEN SUBSTANCES & SYMPTOMS

FUNCTION OF USE

What the client thinks are good things about use: Level of concern about use:

Client's perception of effects of use:

What client would like to do about use:

MANAGEMENT PLAN

RISK SCREEN

STATIC BACKGROUND CURRENT (DYNAMIC)

Suicide Yes No Unk Suicide Yes No Unk Comments

Previous Attempts Expressing ideation Family history Plan/intent Major psych. Diagnosis Highly distressed Serious medical condition Hopeless Separated/divorced Substance abuse Loss of job/retired/role loss Recent life event Lack of resources Self-harm Yes No Unk Self-harm Yes No Unk History of self-harm Actual or thoughts Yes No Unk Yes No Unk Aggression Aggression Previous violence Expressing intent Previous use of weapons Access to means Male Paranoid Criminal history Command hall. Previous ideation Anger, agitation Childhood maladjustment Recent violence Role instability Substance use History of drugs/alcohol Reduced control Yes No Unk Yes No Unk Vulnerability Vulnerability Intellectual disability Cognitive deficit Previous mental illness Self-neglect Absconding Non-compliant Sexual vulnerability Delusional Predatory behaviours Intrusive Serious medical condition Physical illness L M H Poor memory &/ orientation Levelof Risk Disinhibition Suicide Disorganization Self-harm Preoccupation with hospital Aggression Intent on leaving Vulnerability Absconding risk PROTECTIVE FACTORS (factors that reduce the likelihood of negative outcome, e.g. supports)