Transcription of MENTAL HEALTH PLAN ASSESSMENT FORM
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MENTAL HEALTH PLAN ASSESSMENT FORM
MENTAL HEALTH PLAN ASSESSMENT FORM REV. 3. 2016 Page 1 of 6 Every item must be completed. Date Provider Phone Provider Office Address_____ Client Name _____ Consent to treat given by: Self Parent/Guardian Conservator Referral Self School Probation Court CPS APS Parent/Guardian/Conservator Access Unit OtherLiving Arrangement Own House Bio Family Foster Family Group Home SNF B&CEthnicity_____ Language Preferred for Services_____Emergency Contact Relationship PhoneAddress_____Presenting Problem (nature and history) MENTAL HEALTH PLAN ASSESSMENT FORM REV. 3. 2016 Page 2 of 6 Risk ASSESSMENT Current harm to self-risk N/A Ideation Intent Plan Means Describe:History of: Current harm to others risk N/A Ideation Intent Plan Means: Describe:History of: Describe: (note if a particular person is at risk) Assaultive/Combative No Yes If yes, describe:At risk of abuse or victimization No Yes Describe: Have all mandated reporting requirements been met?
orientation, that are important for understanding and engaging the client and for care planning. Preferred language for receiving our services: Culture client most identifies with: Problems client has had because his/her cultural background: ☐ None Sexual orientation issues: ☐ None
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