Meridell Achievement Center

(Place name label here)
MERIDELL ACHIEVEMENT CENTER
Psychosocial Assessment
PATIENT NAME: ______________________________DATE OF BIRTH: ___________ GENDER:
M
F
1. FAMILY OF ORIGIN AND CURRENT CARETAKERS: (Check all that apply)
Biological parents
Mother
Father
Name:
Adoptive parents
Mother
Father
Name:
Step-parents
Mother
Father
Name:
Maternal Grandparents
Mother
Father
Name:
Paternal Grandparents
Mother
Father
Name:
Deceased parent(s)
Mother
Father
Name:
Other:
If not biological parent, how, and at
what age did they come into your care:
None custodial
Mother
Father
Name:
No Rights
Mother
Father
Name:
N/A
Custody of child with (legal guardian):
Name:
N/A
Custody dispute in progress, current status:
N/A Describe custody arrangements (if applicable):
Will bring court documents at admission
Divides time between households.
Describe:
NA
Will fax court documents prior to admission
2. CURRENT HOUSEHOLD MEMBERS LIVING WITH PATIENT: Parents, siblings, relatives and friends
Relationship to Patient
Name
Age
Describe relationship with household member
3. SIGNIFICANT FAMILY MEMBERS / RELATIVES / OTHERS NOT IN SAME HOUSEHOLD:
Relationship to Patient
Name
Age
Describe relationship with Other
4. FAMILY HISTORY OF MENTAL HEALTH ISSUES:
 Bio Maternal History Unknown
Learning Disabilities
Substance Abuse
Neurological
Psychiatric
History of Suicide/Attempts
Aggression
Legal Issues
Incarcerations
Other
Mother’s Side
Relationship to Patient
1
 Bio Paternal History Unknown
Father’s Side
Relationship to Patient
N/A
(Place name label here)
PATIENT NAME: __________________________________
5. DEVELOPMENTAL HISTORY:
Prenatal:
Normal or Unremarkable
Problems with: (e.g., complications during pregnancy/delivery, substance use)
No information available
Developmental Milestones:
Normal Limits
Delayed
Walking:
Early: _________
12-months
Talking in 3-word Sentences:
Early: _________
24-months
Toilet Training:
Early: _________
36-months
Handedness:
Right
Left
No information available
Later:
Later:
Later:
Birth to 1-year:
Problems with:
Normal or Unremarkable
No information available
2 to 5 years:
Problems with:
Normal or Unremarkable
No information available
When this age, was able to; or if currently this age, is able to:
No
Yes Hop or skip
No
Yes Knows first and last name
6 to 12 years:
Problems with:
Normal or Unremarkable
No
No
Yes Interacts with others in play
Yes Able to separate from parents briefly
No information available
At this age was able to, or if currently this age is able to:
For patients 6-8 years old
Fo For patients 9-12 years old
No
Yes Bathes, dresses, combs hair
No
Yes Has a best friend
No
Yes Assumes responsibility
No
Yes Has a hobby
No
Yes Participates in household chores
No
Yes Reads newspaper/magazines
No
Yes Able to verbalize their needs
No
Yes Interested in current news events
No
Yes Plays games with other kids
No
Yes Involved in family discussions
No
Yes Can cooperate in activities
No
Yes Assumes responsibilities for self and belongings
13 to 18 years:
Problems with:
Normal or Unremarkable
If currently in this age group, is able to:
Demonstrates independent decision making
Demonstrates interest in future career goals
The patient currently functions
at age level
No information available
Patient is able to instigate and maintain:
Involvement with peer groups
Involvement in team sports, social activities, sch. act.
above age level
below age level:
Discipline used with patient:
Significant / Relevant issues from childhood impacting current illness (recent, frequent moves, change in schools,
abuse, trauma, medical issues, loss of parent, divorce, abandonment...):
2
(Place name label here)
PATIENT NAME: __________________________________
6. EDUCATION:
Current Grade Level:
Current grades:
Language spoke:
Reading preference:
Learns best by:
Learning Barriers:
History of repeating a grade: No
If Yes, which one:
Improving
Declining
Typically
English
Spanish
Other, please specify:
English
Spanish
Other, please specify:
Listening
Reading
Demonstration
Participation
Eager to learn
Reading & writing difficulties
Speech impediments
Impaired vision
Fatigue
Refusal to attend
Other Description of symptoms and age when
began:
Patient is currently enrolled in school. School Name
Address:
Patient currently is home schooled. Reason:
Not enrolled or attending school due to:
Dropped out
Refuses to attend
Other:
No
Yes School behavioral problems: Details (e.g., age of onset, specific behaviors, school consequences):
No
No
Yes Patient has a history of requiring 1:1 educational aide for behavioral management.
Medical
Behavioral
Yes Patient has a 504 plan for:
Other
No
Yes Special Education Services: What is their qualifying diagnosis?
Date of last IEP meeting
Details (e.g., accommodations, age when services began, services
received):
* Please provide most recent copies of educational plans at the time of admission.
Describe School Strengths:
7. SOCIAL HISTORY:
Patient is able to create friendships.
Patient is able to maintain friendships.
Patient is able to relate to peers in a respectful manner.
Patient is able to relate to adults in a respectful manner.
Patient participates in leisure/recreation/hobby activities.
Never
Never
Never
Never
Never
Rarely
Rarely
Rarely
Rarely
Rarely
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Always
Always
Always
Always
Always
8. BEHAVIOR HISTORY:
Indicated behaviors in the last year
 Withdrawn or Sad
 Isolating
 Low Self Esteem
 Expressed Hopelessness
 Loss of Interest in Activities
 Problems Functioning in Groups
 Expresses Strange Thoughts
 Can’t Make Decisions
 Overwhelmed
 Cries Easily
 Worried / Anxious
 Separation Anxiety
 Specific Fears or Phobias
 Afraid to Sleep Alone
 Panic Attacks
 Lots of Physical Complaints
 Self-Harm/ Mutilation
 Pulling out Hair, Eyelashes, Brows
 Refusal to Eat
 Binge Eating
 Self-Induced Vomiting
 Hides Food/Hoarding
 Poor Social Skills
 Easily Lead Astray
 Poor Judgment
 Can’t Delay Wants
 Low Frustration Tolerance
 Extreme Impulsivity
 Fails to Learn from Experience
 Disregard for Others Rights
 Inability to Set Goals
 Electronic Misuse
3
 Gaming Obsessions
 Memory Lapses
 Blames others for Their Problems
 Trouble Sitting Still
 Trouble Paying Attention
 Racing Thoughts
 Hyper-talkative
 Fixation on Task
 Repetitive Behaviors
 Obsessing
 Bores Easily/Craves Stimulation
 Unrealistic Goals
 Grandiose Sense of Self Worth
 Disregard of Consequences
 Disrespectful
 Argumentative
 Defiant
 Refusing Chores
 Cursing at Authority
 Over-Reacts to Events
 Temper Tantrums
 Loss of Control
 Raging
 Intimidating
 Verbal Threats /Abuse to Others
 Physically Threatening
 Threatens with a weapon
 Setting Fires
 Vandalism
__________________________
(Place name label here)
PATIENT NAME: __________________________________
9. ELOPEMENT:
NO HISTORY of RUNNING AWAY
No
Yes Threatens to run away.
No
Yes Interventions have prevented elopement.
No
Yes Patient has run away from home. When did they last run?
If yes, frequency,
Is it planned?
Where did they go?
How long were they gone?
How did they get back home?
No
Yes Put themselves in harm’s
way during elopement. Details:
No
Yes Patient has run away while
in a treatment setting. Details:
10. HISTORY OF SUICIDAL IDEATIONS/ATTEMPTS:
NO HISTORY of SUICIDAL IDEATIONS
No
Yes History of self-harming behaviors, describe: Head-banging
Scratching
Biting
Hitting
Pulling out or shaving hair, eyelashes or eyebrows
Cutting
Burning
Self piercing
Self-tattooing
Other;
Patient’s mood during suicidal ideations Angry
Sad
Depressed
Manipulative
Other
No
Yes Patient has verbalized suicidal ideations, when:
No
Yes Patient has verbalized plan, describe:
No
Yes Patient has made a suicidal gesture/attempt. If yes, give details.
No
Yes Suicidal gesture could / would have resulted in patients death without interventions.
Date
Age
Method
Injury
Treatment / Outcome
No
No
Yes Patient has access to a gun or other weapons
Yes There are guns or other weapons in the
home, describe how they are secured:
Yes There are other weapons in the home associated with hobbies or collections, describe how they are
No
secured:
No
Yes There are other potentially dangerous items in the home (i.e. medications), describe how they are
secured:
If weapons and/or other potentially dangerous items in the home are not secured, how will this be managed in the
future?
No
Yes Patient has access to lethal means
other than home environment, describe:
11. HISTORY OF VIOLENT / AGGRESSIVE / ANTISOCIAL BEHAVIORS:
No
Yes Patient has a history of violent or aggressive behaviors
No
Yes Aggressive behaviors have been directed towards;
Parents
Siblings
Peers
School
Authority figures
In treatment settings
Others:
No
Yes Aggressive behaviors are escalating and/or are more frequent
No
Yes Patient destroys own property without apparent profit or gain
No
Yes Patient hides or attempts to hide aggressive acts
No
Yes Patient exposes self to physical harm when aggressive
No
Yes Physical aggression appears to be without gain or purpose
No
Yes Patient can control behavior when aggressive
No
Yes Patient aggression is unplanned, out of the blue
No
Yes Patient is very careful to protect self when aggressive
No
Yes Patient is completely out of control when aggressive
No
Yes Patient plans aggressive acts
No
Yes Patient steals from; family
friends school stores neighbors
others
No
Yes Patient experiences rapid mood swings
No
Yes Patient experiences paranoid ideation
No
Yes Patient has history of delusions or command hallucinations prompting them to be aggressive
4
(Place name label here)
PATIENT NAME: __________________________________
VIOLENT/AGGRESSIVE BEHAVIOR: (continued)
No
Yes Patient vandalizes or destroys others property or belongings
No
Yes Patient has been physically aggressive with a weapon. Describe (e.g. patient’s age, victim, weapon
used, extent of injury to victim):
No
Yes Patient has caused physical harm
(injured) others. To what extent?
No
Yes Patient has been physically aggressive
and / or cruel to animals. Describe:
No
Yes Patient has expressed a plan to retaliate against someone. Who:
How?
What are the precipitating events that typically
trigger the patient’s aggressive behaviors?
Types of physical aggression used toward others:
Pushing
Punching
Shoving
Biting
Hitting
Scratching
Head Butting
Pushing Down
Kicking
Stabbing
Choking
Smothering
12. LEGAL HISTORY:
No
Yes Patient has been arrested, describe (e.g., patient age, offense, outcome):
NO LEGAL ISSUES
No
Yes Patient is currently on probation/parole. Name and county of Probation Officer:
No
Yes Patient has charges pending, describe (e.g., patient age, offense, court date):
No
Yes Patient has a history of other law enforcement interventions. Describe:
No
Yes Current illness has affected
legal history, describe:
13. PATIENT HISTORY OF ALCOHOL AND DRUG USE:
Suspected, unconfirmed
Experimentation
Becoming problematic
Generally uses
Alone
With others
How does the patient procure or pay for drugs?
Check all used;
Caffeine
Marijuana
Barbiturates
Diet Aids / Diuretics
Stimulants
Inhalants
Laxatives
Pain Medications
Methadone
Over the counter meds
Steroids
Crystal Meth
Tobacco
Sedatives
Hallucinogens
Alcohol
Tranquilizers
Cocaine/Crack
Substance
Checked or Other
No
No
No
Type
Age of First
Use
Date of Last
Use
Age Regular
Use Began
NO HISTORY of USE
Big problem
Opiates
Ecstasy / GHB
PCP
Prescriptions
Current Use
Pattern
Highest Quantity
in 24-hours
Yes Diagnosis of Chemical Dependency / Abuse / Drug of Choice:
Yes Treatment previously received for drug use  Therapy / Counseling  Hospitalization / Rehab
Yes
N/A Has used again since treatment? How soon after treatment?
5
(Place name label here)
PATIENT NAME: __________________________________
14. SEXUAL:
No
Yes Patient is sexually active.
No
Yes
N/A
Patient practices safe sex.
Sexual behaviors were with / toward:
Same age peers
Younger
Older
Parents
Opposite sex
Same sex
Both male and female
Siblings
Animals
Age of patient
when first
occurred
Sexual Behaviors
Please check all that apply:
Sexual preoccupation
Sexually explicit talk
Sexually explicit writings/drawings
Has used electronic media for “sexting”/sex Chat rooms /
viewing pornography / posting inappropriate pictures of self
Engaged in voyeurism/peeping
Exposed self to others
Sexually promiscuous
Masturbation in presence of others
Acted out sexually in a treatment setting
Touched others sexually without their permission
Sexually aggressive / predatorial
Gender Identity Issues
Has identified sexual preference as
Heterosexual
Bi-Sexual
Frequency and Explanation
Gay/Lesbian
Other
No
Yes Has experienced a sexual assault or
been victimized. Age/perpetrator/circumstances:
No
Yes
Was this suspected abuse of patient reported to a State protective service?
Please provide additional information on checked behaviors:
No
Yes Received serious consequences due to sexual behaviors (i.e. school expulsion/suspension,
legal /social services involvement). What age was patient?
What were charges?
No
No
No
Yes Patient accepts responsibility for their sexual behavior.
Rarely Mostly Yes Patient is able to manage sex urges.
Yes Has patient received treatment
for sexual behaviors. Describe:
15. BEREAVEMENT:
Relationship
to Patient
Name of
Person/Other
Type of loss (death,
divorce, etc.)
Age of Patient
at time of loss
How has this loss affected the patient?
No
Yes There are cultural/religious/ethnic factors affecting patient’s bereavement process:
Explain:
No
Yes Patient’s current illness is affected by the loss, explain:
No
Yes Patient is involved in community
bereavement resources, describe:
6
(Place name label here)
PATIENT NAME: __________________________________
16. CULTURAL INFLUENCES, RELIGIOUS BACKGROUND, AND CURRENT ACTIVITY:
No
Yes Patient has expressed a belief system or spiritualness:
No
Yes Patient has a religious affiliation:
No
Yes Patient attends religious services, name of church/temple:
No
Yes Patient’s affiliation with a place of
worship is part of his/her support system, explain:
No
Yes Patient’s current illness has
affected his/her spiritual life, explain:
Patient and family’s cultural/ethnic background:
 No  Yes The family has specific cultural/ethnic/religious factors that should be considered during treatment,
Explain:
Inpatient hospitalization (Acute), Residential Treatment Center (RTC), Intensive Outpatient
17. DIAGNOSTIC HISTORY: (The patient has previously been diagnosed with)
 Adjustment Disorder
 Anxiety Disorder
 ADD / ADHD
 Autism Spectrum Disorder
 Bipolar Disorder
 Cerebral Dysrhythmia
 Conduct Disorder
 Disruptive Mood Dysregulation
 Eating Disorder
 Fetal Alcohol Syndrome
 Impulse Control Disorder
 Intermittent Explosive Disorder
 Learning Disorder
 Major Depressive Disorder
18. HISTORY OF PREVIOUS TREATMENT:
(Most Recent First)
Partial Hospitalization (PHP)
Name of Facility
No
No
No
Reason for
Admission
 Post-Traumatic Stress Disorder
 Mood Disorder
 Neurodevelopmental Disorder  Psychosis
 Obsessive Compulsive Disorder  Reactive Attachment Disorder
 Oppositional Defiant Disorder  Schizoaffective Disorder
 Substance Abuse
 Paranoid Disorder
 Other __________________
 Personality Disorder
 Pervasive Development Disorder Other __________________

No History of Previous Treatment
Dates of
Treatment
Sending Records
To Meridell
Results of Treatment
Positive Negative None
Positive Negative None
Positive Negative None
Positive Negative None
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
Yes Patient placed in a private bedroom due to patient behaviors (e.g. aggression, sexual acting out),
Specify reason:
Yes Did patient required special staffing (e.g. 1:1, Close observation)? Specify:
Yes Did patient require seclusions, physical holds or injections due to behavioral issues?
Describe:
19. OUTPATIENT PROVIDERS:
No History of Previous Treatment
(Therapist, Psychiatrist, Outpatient Therapy, Support Groups, others in the last couple of years)
Providers
(Most Recent First)
Phone
& Fax #
Treatment
Dates
Release of
Information
Signed to MAC
 Yes  No
 Yes  No
 Yes  No
 Yes  No
No
No
Treatment Results
& Email Address
 Positive  Negative  None
 Positive  Negative  None
 Positive  Negative  None
 Positive  Negative  None
To Resume
Therapy w/ Pt.
After Discharge
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Yes I have provided all requested contact information on the above (Outpatient) providers, to enable
Meridell to establish the necessary lines of communication, re: the aftercare & treatment of my child.
Yes I would like assistance identifying new Outpatient mental health providers for our family.
7
(Place name label here)
PATIENT NAME: __________________________________
20. COMMUNITY RESOURCES CURRENTLY BEING USED BY PATIENT/FAMILY:
Resource
Used to/for
21.
Patient’s Primary Residence with:
Name:
Patient’s Secondary Residence with:
Name:
Address:
Address:
Home #
Cell #
Other #
Home #
Cell #
Other #
21. PRECIPITATING EVENTS NECESSITATING TREATMENT INTERVENTIONS AT THIS TIME:
Completed By
Email Address
Relationship to Patient
8
Date
PC-56-A 7/2014