MH 532 ADULT

Revised 02/04/14 FULL ASSESSMENT Page 1 of 7

Date of first assessment contact: ______________

Assessing Practitioner (Name and Discipline): _____________________________________

Client/Others Interviewed: ___________________________________________________________________________________________

I. Demographic Data & Special Service Needs:

DOB: ______ Gender: ______ Ethnicity: _______________ Marital Status: __________________________
Referral Source:

Non-English Speaking, specify language used for this interview: _______________________________________________

Were Interpretive Services provided for this interview? Yes No
Cultural Considerations, specify: ___________________________________________________________________________________
Physically challenged (wheelchair, hearing, visual, etc.) specify: __________________________________________________________
Access issues (transportation, hours), specify: _________________________________________________________________________

II. Reason for Referral/Chief Complaint

Describe precipitating event(s)/Reason for Referral,

Current Symptoms and Behaviors (intensity, duration, onset, frequency) and Impairments in Life Functioning caused by the
symptoms/behaviors (from perspective of client and others):

Client Strengths (to assist in achieving treatment goals)

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

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Revised 02/04/14 FULL ASSESSMENT Page 2 of 7
III. Mental Health History:
History of Problem Prior to Precipitating Event: Include treated & non-treated history.

Impact of treatment and non-treatment history: on the client's level of functioning, e.g., ability to maintain residence, daily living and
social activities, health care, and/or employment.

Psychiatric Hospitalizations: Yes No Unable to Assess

If yes, describe dates, locations, and reasons

Outpatient Treatment: Yes No Unable to Assess

If yes, describe dates, locations and reasons.

Past Suicidal/Homicidal Thoughts/Attempts including dates, threat, intent, plan, target(s), access to lethal means, method used:

History of Trauma or Exposure to Trauma: Yes No Unable to Assess

Has client ever (1) been physically hurt or threatened by another, (2) been raped or had sex against their will, (3) lived through a disaster, (4)
been a combat veteran or experienced an act of terrorism, (5) been in a severe accident, or been close to death from any cause, (6) witnessed
death or violence or the threat of violence to someone else, or (7) been the victim of a crime?

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT

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Revised 02/04/14 FULL ASSESSMENT Page 3 of 7
IV. Medications
List "all" past and present psychotropic medications used, prescribed/non-prescribed,by name, dosage, frequency. Indicate from client's
perspective what seems to be working and not working.
Medication Dosage/Frequency Period Taken Effectiveness/Response/Side Effects/Reactions

General Medication Comments (include significant non-psychotic medication issues/history):

V. Substance Use/Abuse
“MH659 -Co-Occurring Joint Action Council Screening Instrument”
1. Were any of the questions checked “Yes” in Section 2 “Alcohol & Drug Use”? Yes* No If yes, complete MH633
2. Were any of the questions checked “Yes” in Section 3 “Trauma/Domestic Violence”? Yes No If yes, answer 2a
2a. Was the Trauma or Domestic Violence related to substance use? Yes* No If yes, complete MH633
Be sure to document re: Trauma or Domestic Violence in Part A of “Psychosocial History” on page 3 of the Initial Assessment.

Does the client currently appear to be under the influence of alcohol or drugs? Yes No Unable to Assess
If yes, When was the last time the client used alcohol or drugs?

Has the client ever received professional help for his/her use of alcohol or drugs? Yes No Unable to Assess
Comments on alcohol/drug use:

How is Mental Health impacted by substance use (Clinician’s Perspective)? Must be completed if any services will be directed towards
Substance Use/Abuse.

* MH 633 “Supplemental Co-Occurring Disorders Assessment” completed on: _______________

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT

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Revised 02/04/14 FULL ASSESSMENT Page 4 of 7
VI. Medical History
MD Name: _______________________________ MD Phone: ___________________ Date of Last Physical Exam: ______________
Major medical problem (treated or untreated) (Indicate problems with check: Y or N for client, Fam for family history.)
Fam Y N Fam Y N Fam Y N Fam Y N
Seizure/neuro disorder Cardiovascular Liver disease Diarrhea
disease/symp
Head trauma Thyroid Renal Cancer
disease/symp disease/symp
Sleep disorder Asthma/lung disease Hypertension Sexual dysfunction
Weight/appetite chg Blood disorder Diabetes Sexually trans
disease
Allergies (If Yes, specify):
Sensory/Motor Impairment (If Yes, specify):
Pap smear Mammogram HIV Test Pregnant
If yes, date: If yes, date: If yes, date: If yes, due date:
__________ __________ __________ __________

Comments on above medical problems, other medical problems, and any hospitalizations, including dates and reasons.

VII. Psychosocial History

Please state specifically how Mental Health status directly impacts each area below; Be sure to include the client’s strengths in each area.
Education
Special Education: Yes No Unable to Assess Learning Disability: Yes No Unable to Assess
Motivation, education goals, literacy skill level, general knowledge skill level, math skill level, school problems, etc:

Employment History, Readiness for Employment and Means of Financial Support

Current Paid Employment: Yes No Unable to Assess Military Service: Yes No Unable to Assess
Work related problems, volunteer work, money management, source of income, longest period of employment, etc:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT

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Revised 02/04/14 FULL ASSESSMENT Page 5 of 7
Legal History and Current Legal Status
Arrests/DUI, probation, convictions, divorce, conservatorship, parole, child custody, etc:

Current Living Arrangement and Social Support Systems

Type of living setting, problems at setting, community, religious, government agency, or other types of support, etc:

Dependent Care Issues

Number of Dependent Adults: ______ Number of Dependent Children: _______
Ages of children, school attendance/behavior problems of children, special needs of dependents, foster care/group home placement issues,
child support, etc:

Family and Relationships

History of Mental Illness in Immediate Family: Yes No Unable to Assess
Alcohol/Drug Abuse in Immediate Family: Yes No Unable to Assess
Family constellation, family of origin, family dynamics, cultural factors, nature of relationships, domestic violence, physical or sexual abuse,
home safety issues, family medical history, family legal/criminal issues

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT

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Revised 02/04/14 FULL ASSESSMENT Page 6 of 7
VIII. Mental Status Evaluation

Instructions: Check all descriptions that apply

General Description Mood and Affect Thought Content Disturbance
Grooming & Hygiene: Well Groomed Mood: Euthymic Dysphoric Tearful None Apparent
Average Dirty Odorous Disheveled Irritable Lack of Pleasure
Bizarre Hopeless/Worthless Anxious Delusions: Persecutory Paranoid Grandiose
Comments: Known Stressor Unknown Stressor Somatic Religious Nihilistic
Comments: Being Controlled
Comments:

Eye Contact: Normal for culture

Little Avoids Erratic Affect: Appropriate Labile Expansive
Comments: Constricted Blunted Flat Sad Ideations: Bizarre Phobic Suspicious
Worried Obsessive Blames Others Persecutory
Comments: Assaultive Ideas Magical Thinking
Irrational/Excessive Worry
Motor Activity: Calm Restless Sexual Preoccupation
Agitated Tremors/Tics Posturing Rigid Perceptual Disturbance Excessive/Inappropriate Religiosity
Retarded Akathesis E.P.S. None Apparent Excessive/Inappropriate Guilt
Comments: Comments:
Hallucinations: Visual Olfactory
Tactile Auditory: Command
Persecutory Other Behavioral Disturbance
Speech: Unimpaired Soft Comments:
Slowed Mute Pressured Loud Behavioral Disturbances: None Aggressive
Excessive Slurred Incoherent Uncooperative Demanding Demeaning
Poverty of Content Self-Perceptions: Depersonalizations Belligerent Violent Destructive
Comments: Ideas of Reference Self-Destructive Poor Impulse Control
Comments: Excessive/Inappropriate Display of Anger
Manipulative Antisocial
Comments:
Interactional Style: Culturally congruent
Cooperative Sensitive
Thought Process Disturbances
None Apparent
Guarded/Suspicious Overly Dramatic
Negative Silly
Comments:
Associations: Unimpaired Loose Suicidality/Homicidality
Tangential Circumstantial Confabulous
Flight of Ideas Word Salad Suicidal: Denies Ideation Only
Comments: Threatening Plan
Comments:
Orientation: Oriented
Disoriented to:
Concentration: Intact Impaired by:
Time Place Person Situation
Rumination Thought Blocking
Comments:
Clouding of Consciousness Fragmented
Comments: Homicidal: Denies Ideation Only
Threatening Target Plan
Comments:
Intellectual Functioning: Unimpaired
Abstractions: Intact Concrete
Impaired
Comments:
Comments:
Other
Judgments: Intact
Memory: Unimpaired
Impaired re: Minimum Moderate Severe Passive: Amotivational Apathetic
Impaired re: Immediate Remote Recent
Comments: Isolated Withdrawn Evasive Dependent
Amnesia
Comments: Comments:

Insight: Adequate
Impaired re: Minimum Moderate Severe
Fund of Knowledge: Average
Comments: Other: Disorganized Bizarre
Below Average Above Average
Comments: Obsessive/compulsive Ritualistic
Excessive/Inappropriate Crying
Serial 7’s: Intact Poor Comments:
Comments:

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT

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Revised 02/04/14 FULL ASSESSMENT Page 7 of 7
IX. Summary and Diagnosis
:I. Diagnostic Summary: (Be sure to include assessment for risk of suicidal/homicidal behaviors, significant strengths/weaknesses,
observations/descriptions, symptoms/impairments in life functioning, i.e., Work, School, Home, Community, Living Arrangements, etc, and
justification for diagnosis)

II. Admission Diagnosis (check one Principle and one Secondary)

Axis I Prin Sec Code __________ Nomenclature ______________________________
(Medications cannot be prescribed with a deferred diagnosis)
Sec Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Axis II Prin Sec Code __________ Nomenclature ______________________________
Sec Code __________ Nomenclature ______________________________
Code __________ Nomenclature ______________________________
Axis III ___________________________________ Code ___________
___________________________________ Code ___________
___________________________________ Code ___________
Axis IV Psychological and Environmental Problems which may affect diagnosis, treatment, or prognosis
Primary Problem #: ___
Check as many that apply:
1. Primary support group 2. Social environment 3. Educational 4. Occupational
5. Housing 6. Economics 7. Access to health care 8. Involve w/Legal Sys
9. Other psychosocial/environmental 10. Inadequate information
Axis V Current GAF: ______ DMH Dual Diagnosis Code: __________

III. Specialty Mental Health Services Medical Necessity Criteria:

1. Medi-Cal Specialty Mental Health Included Diagnosis Yes No
2. Significant impairment in life functioning due to the Included Diagnosis Yes No
3. Expectation that proposed interventions can impact the client’s condition Yes No
4. Mental Health Condition will not be responsive to physical health care based treatment Yes No
IV. Disposition/Recommendations/Plan

V. Signatures
__________________________________ __________ ________________________________ __________
Assessor’s Signature & Discipline Date Co-Signature & Discipline Date

This confidential information is provided to you in accord with State and Federal laws
and regulations including but not limited to applicable Welfare and Institutions code, Name: IS#:
Civil Code and HIPAA Privacy Standards. Duplication of this information for further
disclosure is prohibited without prior written authorization of the client/authorized
representative to whom it pertains unless otherwise permitted by law. Destruction of this Agency: Provider #:
information is required after the stated purpose of the original request is fulfilled. Los Angeles County – Department of Mental Health

ADULT FULL ASSESSMENT