Initial AssessmentInitial AssessmentInitial Clinical Assessment Family Connections, LLC 1643 Warwick Avenue, #200, Warwick RI 02889 Phone: 401-952-8188 Fax: 401-385-9410 familyconnections@familyconnectionsri.com familyconnectionsri.com Please enable JavaScript in your browser to complete this form.LayoutDateStaff Conducting IntakeCase NumberLayoutReferral Source NameSelf-Referred NameReferral SourceFamily Connections ClinicianCommunity Behavioral Health CenterSubstance Use ProviderHealthcare Provider - HospitalCommunity Service ProviderHousingLaw EnforcementDCYFLayoutAgency NameAgency EmailAgency PhoneConsent/release with referral received from AgencyYesNoN/A - Self Referral OnlyReason For ReferralClient InformationClient Name *FirstLastGenderFemalMaleTransgenderClient Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client SS NumberRace-Ethnicity:Private Insurance ProviderPrivate Insurance NumberKatie Becket Waiver:YesNoKatie Becket Waiver Since When?Primary LanguageEnglishSpanishOtherInterpreter Services Needed?YesNoPreferred Client's Name *Pro/nouns:Client AgeMIDCitizenshipU.S CitizenImmigrant/refugeePending immigration statusState Insurance ProviderState Insurance NumberOther Insurance DescribePreferred LanguageInterpreter Services Needed? Hearing ImpairedSeeing ImpairedInterpret Accommodations:Client's Social HistoryClient's Presenting Plan/Reason for ReferralHome: A stable and or safe place to liveLayoutIs the client living in a independent living?YesNoPatient Address Address Line 1Address Line 2CityRhode IslandAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf you are not living independent, are you homeless?YesNoIf Yes how long?Are you living in a Shelter?YesNoIf Yes how long?Are you living in a Group Home?YesNoIf Yes how long?Patient PhoneIs it ok to send text messages?YesNoIs it okay to leave messages?YesNoSpecial instructions when calling:Explain Current Living Sutation:Household Make UpLayoutNameNameNameNameNameNameAgeAgeAgeAgeAgeAgeRelationshipRelationshipRelationshipRelationshipRelationshipRelationshipNeeds, concerns and goals to be addressed:IN CASE OF AN EMERGENCY, PLEASE NOTIFYLayoutContact NamePhoneIs it okay to leave message from agency?YesNoSpecial instructions when calling:If applicable, are they aware of you receiving Behavioral Health Services?YesNoRelationshipAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePURPOSE: Meaningful daily activities, such as job, school, volunteerism, family caretaking, income and resources to participate in the community. (Obtain ID, food stamps, etc).LayoutHighest level of Education Completed:Please SelectPrimary School (grades K-6)Secondary School (grades 7-12)High School Diploma or GEDSome CollegeAssociate's DegreeBachelor's DegreeSome Graduate SchoolMaster's DegreeSome post-grad studiesPh.DProfessional CertificateDo you work?YesNoIf Yes, Location:Do you have any children under 18?YesNoIf Yes, do they live with you?YesNoDo you have Transportation?YesNoCarPublic TransportationDo you have any professional certifications?Do you receive any of the following?UnemploymentSDITGFASSIGPAFood StampsOtherIf Other Explain:Needs, concerns, and goals to be addressed:Legal StatusCurrently, is DCYF involved?YesNoLayoutDCYF WorkerDCYF Worker PhoneHave you ever been arrested?YesNoAre you currently on ProbationYesNoLayout (copy)Probation OfficerProbation Officer's PhoneAre you currently on ParoleYesNoLayout (copy) (copy)Parole OfficerParole Officer's PhoneDo you have any court stipulations?YesNoIf yes what are they?Needs, concerns, and goals to be addressed:Health: Managing one's disease as well as living in a physical and emotional healthy way Symptoms Currently Experiencing Sleep DisturbanceMood LabilityLoose AssociationsLaxativePsychomotor RetardationAppetite DisturbancePoor ConcentrationParanoid IdeationAlcoholDepressed MoodPhobiasAggressive BehaviorIrritabilityDelusionsAbusingLow EnergyPanic AttacksOppositional/DefiantIllicit DrugsHallucinationsAnorexiaEpisodic CryingAnxietyTangentialRx MedsObsessions/CompulsionsSexual DysfunctionMedical InformationLayoutDo You have any allergies- Food, Medicine other?YesNoIf you have any allergies, please explain:Do you have any medical conditions?YesNoIf yes, what are they:Do you smoke?YesNoIf yes, would you like to stop?Are you taking any prescribed Medications?Do you have trouble adhering to medication regimen? If yes, why?Family History of Medical Diagnosis/treatment:Do you have a primary care provider?YesNoDate of last time you had a physical?Medical Office or Clinic NameDoctor Name:Medical Office or Clinic Phone NumberDate of Last Medical Appointment:Did client keep appointment?YesNoDo you have difficulty keeping medical appointments?YesNoMental Status Exam - Clinician OnlyCheck as appropriateAttentionGood (on task 90%)Fair (on task 75%)Easily DistractedHighly DistractibleAffectAppropriateLabileExpansiveConstrictedBluntedMoodNormalDepressedAnxiousEuphoricOtherOther: *ApperanceWell-groomedDisheveledBizarreInappropriateOtherOther *Motor ActivityCalmHyper ActiveAgitatedTremorsTicsMuscle SpasmsThought ProcessIntactCircumstantialTangentialFlight of IdeasLoose AssociationsHallucinationsNoneAuditoryVisualOlfactoryCommandDelusionsNonePersecutoryGrandoiseReligiousOtherOtherMemoryIntactImpaired: (Check)ImpairedSelect OneImmediateRecentRemoteJudgement/InsightIntactImpaired: (Check)ImpairedSelect OneMildModerateSevereOrientationAll SpheresImpaired: (Check)Impaired *PersonPlaceTimePurposeSuicidalNoneIdeationPlanIntentMeansHomicidalNoneIdeationPlanIntentMeansSpeechNormalSlowSlurredPressuredRapidImpulse ControlAppropriateLimitedPoorOtherOtherHistory of SI or HIHistory of Self-Injury:Layout (copy)Have you ever been diagnosed with a Mental Health Condition?YesNoWhat mental conditions have you been diagnosed with? Include YearList any mental health medications client is currently taking, if any:If applicable, does client have trouble adhearing to medication regimen?YesNoIf yes, why?Does Client have a medical case manager?YesNoIf yes, Case Manger's Name:Case Manger's PhoneCase Manger's AgencyDo you have a mental health provider?YesNoIf yes, provider Office or Clinic NameMental Health Provider Name:Date of last mental health appointment?Did client keep appointment? YesNoDo you have difficulty keeping medical appointments?YesNoFamily History of Mental Health Diagnosis/Treatment:Do you have a history/current Sexual/Physical abuse:Substance and Alcohol usePlease describe client's alcohol and/or drug use in the past 6 monthsHas client ever been admitted to an alcohol or drug treatment facility?YesNoLocation(s) and date(s) of treatment past year:Addiction/Chemical Use & Dependency AssessmentClients 12 years and olderLayoutTobaccoAlcoholCannabisNicotinePrescribed/OTC MedicinesHave you ever overdosed?YesNoIf Yes, how many times?If Yes, last time?Do you know how to use naloxone?YesNoDo you need some naloxone?YesNoTobacco FrequencySelect OptionCurrentlyBy HistoryN/AAlcohol FrequencySelect OptionCurrentlyBy HistoryN/ACannabis FrequencySelect OptionCurrentlyBy HistoryN/ANicotine FrequencySelect OptionCurrentlyBy HistoryN/APrescribed/OTC Medicines FrequencySelect OptionCurrentlyBy HistoryN/AFamily History of Addiction/Chemical Abuse:Needs, concerns, and goals to be addressed:Community : Relationship and Social Networks that provide support, hope and encouragmentDo you have any family supports?YesNoIf yes, who and how do they support you?Cultural Variables/Religious Practices/BeliefsDo you attend AA, NA or other support meetingsYesNolf yes, where and how of often?Think of a time in your life where you felt you were at your best (emotionally stable), what did that look like for you?What kinds of socializing activities do you like to do?Needs, concerns, and goals to be addressed:Client meets criteria for the following DSM V diagnosis/diagnoses:Primary DiagnosisInitial Treatment plan: *Community Health Worker services for client needed?YesNo (Please put in referral in NUMO system)Home: Having a stable and safe place to live Health: Overcoming or managing one's disease(s) or symptoms, and making informed, healthy choices that support physical and emotional well being Purpose: conducting meaningful daily activities, such as a job, school, volunteerism, family caretaking or creative endeavors and the independence, income and resources to participate in society Community: Having relationships and social networks that provide support, friendship, love and hopeFirst PlanCHW Goals using SAMSHA four Dimensions of recovery1. HomeLayoutGoalNotes2. HealthLayout (copy)GoalNotes3. CommunityLayout (copy) (copy)GoalNotes4. PurposeLayout (copy) (copy) (copy)Goal NotesLayoutStaff Signature Clear Signature DateLayoutReviewed By:Clinician AssignedClinician EmailDateSubmit