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05/2016V1 Standard Diagnostic Assessment Tool Approved for use with South Country Members South Country Health Alliance 2300 2300 Park Drive, Suite 100 Owatonna, MN 55060. Phone (866) 722-7770 Fax (507) 431-6329 Date of Interview: Member Demographics Member Name: Member PMI: Member DOB/Age: Member Address: Member City, State, Zip: List Mental Health Diagnosis with ICD 10 Code: 1. 2. 3. 4. 5. (Please attach WHODAS 2.0 or include version used and score) Presenting Symptoms Anxious Guilty feelings Weight loss Sexual issues Ashamed Heavy feeling Difficulty breathing Sleep problems Unable to enjoy self Hopelessness Dizziness Wound up Depressed/Sad Irritable/angry/lose temper Headaches Discomfort Elevated mood Loneliness Heart racing Isolative Excessive Worry Low self-esteem Increased appetite Withdrawn Feel inferior Paranoia Weight gain Auditory hallucinations Feel unworthy Tense feelings Low energy/tired Distressing memories Feel numb Aches/pain Night terrors Disturbing thoughts Frequent mood swings Decreased appetite Numbness/tingling Delusions Poor concentration Racing thoughts Visual hallucinations Thoughts/urges of self-harm Cry easily/often Impulsive Wants to die Wants to harm others Lack motivation Reactive Repetitive actions Restless/fidgety Shaking Violent Actions of self-harm Reason for referral: Member’s perception of his/her condition: Duration of symptoms: Potential consequences of symptoms: Contributing contextual non-personal factors: Cultural Influences and Client Impact: Prognosis: Current Life Situation Current living situation: Current Financial Status: Highest Education Level Completed: Employment Status: Current Relationship Status: Children/Step Children? Primary Care Physician: YES NO If yes, how many? Primary Care Clinic: Ages? Page 1 of 5 pages 05/2016V1 Standard Diagnostic Assessment Tool Approved for use with South Country Members South Country Health Alliance 2300 2300 Park Drive, Suite 100 Owatonna, MN 55060. Phone (866) 722-7770 Fax (507) 431-6329 Any known allergies? YES Current Medication NO Dose 1. 2. 3. 4. 5. 6. 7. 8. If yes, please list: Start Date Current Medication Dose Start Date 9. 10. 11. 12. 13. 14. 15 16. Relevant History Records Review: Mental Health Treatment History: Developmental History: Maltreatment or Abuse History: History of Drug/Alcohol Abuse: Legal History: Health History and Concerns: Family History of Mental Illness and/or Substance Use Disorders: Would you like services specific to language, age, gender, culture, religious preference, race, ethnicity, sexual orientation or disability? YES NO If yes, please specify: Functional Impairment Coping Skills Ability to Care for Self Daily Living Skills Medical/Dental Mental Health Services Financial Management Use of drugs/alcohol Housing/Shelter Education/School Transportation Employment Danger to Self and/or Others Social Legal Interpersonal/Relationship and Environment Other: Strengths and Resources; include extent and quality of social networks: Page 2 of 5 pages Standard Diagnostic Assessment Tool 05/2016V1 Approved for use with South Country Members South Country Health Alliance 2300 2300 Park Drive, Suite 100 Owatonna, MN 55060. Phone (866) 722-7770 Fax (507) 431-6329 How does diagnosis interact with/impact member’s life? Describe how diagnosis criteria is met, duration of symptoms and functional impairment: Clinically Appropriate Services Needed Dialectical Behavior Therapy (DBT) MI/CD Groups / Treatment Psychotherapy County Case Management Assertive Community Treatment (ACT) Health Education/Medication Management/ Nursing Transportation Services Services Intensive Residential Treatment (IRTS) Housing Supports Adult Rehabilitative Mental Health Services (ARMHS) -if this Psychiatry/Medication Management is recommended, please select areas of skills which should be CPS Services addressed below: Crisis Services Communication Skills Budgeting/Financial Community Integration Independent Living Skills Community Support and Resources Interpersonal Skills Training Other Special Considerations Identified Communication Needs: Identified Barriers to Learning: None Reported None Reported TDD/TTY Device Learning Disability/Type Language Interpreter Services needed Inability to read and/or write Other Spoken Language Developmental Disability Assisted Listening Device Other: Other: Mental Status Exam Appearance Clean Neat Unkempt Disheveled Other: Looks Stated Age YES NO Older Younger Eye Contact Appropriate Inappropriate Other: Orientation Memory Attention Perception Motor Activity Cognitive Performance Thought Process Danger to Others Danger to Self Fully Oriented Time Place Person Situation Normal Limits Deficient: Immediate Recent Remote Other: Adequate Inadequate Other: Adequate Inadequate Other: Normal Slowed Restless Agitated Accelerated Other Normal limits Poor memory Low self-awareness Short attention Developmental disability Poor concentration Impaired judgement Slow processing Full Scale IQ is known: Normal limits Accelerated Delusional Paranoid Ruminative Intact Grandiose Tangential Loose association Slowed Hallucination (visual, auditory, tactile) Does not appear dangerous to others Violent temper Threatens others Physical Abuse Hostile Assaultive Homicidal ideation Homicidal threats Homicide attempt Does not appear dangerous to self Suicidal ideation Recent attempt Self-injurious/self-mutilation: Hx of attempt: Current plan/means: Page 3 of 5 pages Standard Diagnostic Assessment Tool 05/2016V1 Approved for use with South Country Members South Country Health Alliance 2300 2300 Park Drive, Suite 100 Owatonna, MN 55060. Phone (866) 722-7770 Fax (507) 431-6329 Sensory Deficits Speech None Speech Hearing Vision Clear Slurring Slowed Loud Soft Pressured Minimal Excessive Incoherent Delayed Fast Other: Mood Euthymic Unremarkable Depressed Tearful Anxious Manic Labile Other: Affect Normal Blunted Congruent Euphoric Incongruent Flat Expansive Labile Other: Insight into Problem Takes responsibility Intellectual insight Emotional insight Slight awareness Blames others Complete denial Judgement Good Fair Poor Impulse Control Good Fair Poor Attitude Cooperative Guarded Withdrawn Uncooperative Oppositional Belligerent /Hostile Apathetic Suspicious Other: Additional observations and others involved in assessment: Narrative: According to the Comprehensive Mental Health Act, the mental health professional conducting this diagnostic assessment must complete the need for the following: CAGE-AID Completed Score: GAIN SS Completed Score: PHQ-9 Completed Score: CASII (For Children Over 6) Completed Score: ECSII (For Children Under 6) Completed Score: LOCUS Completed Score: Serious and Persistent Mental Illness Definition “ A person with a serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the following criteria: (1) The adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months; (2) The adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months’ duration within the preceding 12 months; (3) The adult has been treated by a crisis team two or more times within the preceding 24 months; (4) The adult (i) has a diagnosis of schizophrenia, bi-polar disorder, major depression, or borderline personality disorder; (ii) indicates a significant impairment in functioning; AND (iii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided; (5) The adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s commitment has been stayed or continued; or (6) The adult (i) was eligible under clauses (1) to (5) but the specified time period has expired or the adult was eligible as a child under section 245.4871, subdivision 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided. If #4 or #6 is selected, written opinion must be provided here: Page 4 of 5 pages Standard Diagnostic Assessment Tool 05/2016V1 Approved for use with South Country Members South Country Health Alliance 2300 2300 Park Drive, Suite 100 Owatonna, MN 55060. Phone (866) 722-7770 Fax (507) 431-6329 Severe Emotional Disturbance Definition “ A person with a severe emotional disturbance” means a child who has an emotional disturbance and who meets one of the following criteria: (1) The child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment for an emotional disturbance; or (2) the child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the interstate compact; or (3) the child has one of the following as determined by a mental health professional: i. Psychosis or a clinical depression; or ii. Risk of harming self or others as a result of an emotional disturbance; or iii. Psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past year; or (4) the child, as a result of an emotional disturbance, has significantly impaired home, school, or community functioning that has lasted at least one year or that, in the written opinion of a mental health professional, presents substantial risk of lasting at least one year. If #4 is selected, written opinion must be provided here: Clinician Information and Signature: Mental Health Professional Signature: Date: Printed Name: Agency Name and Address: I am a qualified Mental Health Professional in the following field: Psychiatric Nursing Psychology (LP, LPP) Clinical Social Work Licensed Marriage & Family Therapy Allied Field: Psychiatry Thank you! Page 5 of 5 pages