Comprehensive Clinical Assessment - Cardinal Innovations

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Comprehensive Clinical Assessment Date(s) of assessment:

Clinician completing assessment: Face-to-face time:

Total time spent to complete Record review time:

Member Demographics (Complete this section in its entirety) Member Name: Member ID#:

DOB: Gender: Ethnicity:

Insurance type: Insurance ID #:

Address: Phone #:

Primary language: Referral source:

Legally Responsible Person (LRP):

Participants (Add the names of all the people who are a part of the assessment process. Include those who were face-to-face in the Assessment Participants section and those you reached out to by phone, mail or email in the Collateral Contacts section.)

Assessment participants Relationship to client Date(s) of participation

Collateral contacts Relationship to client Date(s) of participation

Member Name: Member ID#:

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Presenting Problem (Including information from the referral source is recommended; presenting problem should be described in detail.)

Description/reason for referral:

Source of distress:

Associated problems/symptoms (indicate frequency and severity of each):

Medical/General Health History and Current Status (Overview of biological history/issues, physical health, genetic disorders, etc. Coordination of care with primary care physician is highly recommended.)

Current physical health concerns/medical conditions:

Relevant past physical health concerns:

Primary Care Physician Name:

Primary Care Physician Contact Information:

Known allergies:

Genetic disorders:

Physical exam in the past 12 months? (Y/N, include date):

Current pregnancy:

Use of tobacco products/vaping (current or past):

Nutritional needs:

Recent weight loss/gain:


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Speech/hearing/vision impairment:

Past head injuries/TBI:

Immunizations:

Past surgeries:

Eating patterns (as applicable):

Sleeping patterns (as applicable):

Strengths:

Needs:

Risks:

Medication Summary (Include name of current and past medications for physical and psychological health. Fill out each section of chart.)

Name of medication Frequency Dose Adherence Reason for

taking Current or past (include dates)

Side effects or adverse reactions

TBI Screener (If member answers “yes” to question one or two, then complete the Ohio State University TBI Identification below.)

Yes No 1. Have you ever hit your head or been hit on the head, including being told you had a concussion?

Yes No 2. Did you lose consciousness or experience a period of being dazed and/or confused because of theinjury to the head?


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Ohio State University TBI Identification (To be completed if “yes” is answered to either question above, this information needs to be reported to the state here.)

Question Cause, if yes

Yes No

1. In your lifetime have you ever been hospitalized or treated in an emergency room following an injury to your head or neck?

Yes No

2. In your lifetime have you ever injured your head or neck in a car accident or from crashing some other moving vehicle like a bicycle, motorcycle or ATV?

Yes No

3. In your lifetime, have you ever injured your head or neck in a fall or from being hit by something (for example, falling from a bike or horse, rollerblading, falling on ice, being hit by a rock) Have you ever injured your head or neck playing sports or on the playground?

Yes No

4. In your lifetime, have you ever injured your head or neck in a fight from being hit by someone, or from being shaken violently? Have you ever been shot in the head?

Yes No

5. In your lifetime, have you ever been nearby when an explosion or blast occurred? If you served in the military, think about any combat- or training-related incidents

Cause (from above) Did you lose consciousness (LOC)? If yes, how long?

If you had no LOC, were you dazed or did you have a memory gap?

Age at injury

None Less than 30 min

30 min - 24 hrs More than 24 hrs

Yes No



Yes No



Yes No



Yes No

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If more injuries with LOC:

How many? How many greater than 30 minutes?

Longest knocked out? Youngest age of incident?

Have you ever had a period of time in which you experienced multiple repeated impacts to your head (e.g. history of abuse, contact sports, military duty)?

Cause of repeated injury Typical effect Most severe effect Age

Began Ended

Dazed memory gap, No LOC LOC

Dazed memory gap, No LOC Less than 30 min 30 min - 24 hoursMore than 24 hours

Dazed memory gap, No LOC LOC

Dazed memory gap, No LOC Less than 30 min 30 min - 24 hoursMore than 24 hours

Social History (Recreational activities, religious affiliation, community involvement, culture, peer relationships, legal history, sexual orientation, gender identity, immigration, history of discrimination, DSS/DJJ involvement, etc.) The use of ‘NA’ is discouraged for this section.

Description:

Strengths:

Needs:

Risks:

Natural supports:

Cultural considerations:


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Family History (Household members, support systems, family dynamics, military involvement, guardianship status, etc.) The use of ‘NA’ is discouraged for this section.

Description:

Strengths:

Needs:

Risks:

Family history of mental health and/or substance use:

Environment (Living arrangement, issues with living environment, economic issues, availability of food and other resources, transportation issues, safety concerns, etc.) The use of ‘NA’ is discouraged for this section.

Description:

Strengths:

Needs:

Risks:


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Developmental (Milestones reached; information related to IDD, issues during gestation, etc.) The use of ‘NA’ is discouraged for this section.

Description:

Strengths:

Needs:

Risks:

Educational/Occupational History (Grade, academic achievements/problems, disciplinary problems, EC services, employment history, etc.) The use of ‘NA’ is discouraged for this section.

Description:

School/daycare name:

Current grade: Last grade completed if not in school:

Strengths:

Needs:

Risks:


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Employment history:

Psychological/Behavioral Health History The use of ‘NA’ is discouraged for the strengths, risks and needs.

Current behavioral health concerns (psychological symptoms, duration, impact, etc.):

Strengths:

Needs:

Risks:

Additional comments:

Past behavioral health treatment received (include psychiatric hospitalizations): (If member is not able to provide details around the information in this section, provide as much detail as possible.)

Type of treatment (or name of service) Who provided the treatment Dates of

treatment Outcome of Treatment


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Substance Use History (Complete this section in its entirety, including as many details as possible.)

No known history of substance use

Drug Age of 1st use

Frequency of use Amount used Route Last use

Withdrawal symptoms

Problems related to use

Caffeine

Nicotine

Alcohol

Cannabis

Cocaine

Hallucinogens

Ecstasy

Inhalants

Opiates

Barbiturates

Benzodiazepines

Other:

Additional Comments:

ASAM Severity Profile (Only for those with a diagnosis of substance use disorder(s))

Dimension 1: Acute Intoxication and Withdrawal Potential

Dimension 2: Biomedical Conditions and/or Complications

Dimension 3: Emotional, Behavioral, or Cognitive Conditions and/or Complications

Dimension 4: Readiness to Change

Dimension 5: Relapse, Continued Use, or Continued Problem Potential

Dimension 6: Recovery Environment

ASAM Placement Level


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Trauma History (Recommend use of trauma screening tool, ask about any significant stressors, or any event that caused significant stress.)

Abuse history (physical, sexual, emotional):

History of neglect/basic physical needs not met:

Exposure to domestic/family violence:

Exposure to community violence:

Family history of violence and/or suicide:

Serious accident/illness/medical procedure:

Exposure to school violence and/or bullying:

Exposure to drug/substance abuse or related activity:

Incarceration and/or witnessing arrest of family/caregiver(s):

Traumatic death of a loved one:

Immigration trauma:

Natural disaster/war/terrorism:

Separation from/change in primary caregiver:

Homelessness:

Other significant stressors:

Symptoms related to trauma:

Additional comments:


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Risk Assessment Current risk of harm to self or others:

Suicidality: Thoughts Ideation Intent Plan Gestures Means

Homicidality: Thoughts Ideation Intent Plan Means

History of harm to self or others (suicidal or homicidal ideation/intent/behaviors):

Risk-taking behaviors:

Access to firearms/weapons:

Strengths/protective factors:

Crisis/safety plan (if applicable):


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Mental Status Exam (Based on observations of the member during the assessment, use comment sections for any clarification that may be needed.)

Orientation

Person: Place: Time:

Situation:

Comments:

General Appearance

Appropriate forage/development

Overweight Disheveled

Stiff Stooped

Well-groomed Dirty

Other:

Comments:

Attitude

Cooperative Resistant Hostile

Reserved Negative Sarcastic

Suspicious Guarded

Pleasant Open

Appropriate to context Dependent Passive aggressive

Other:

Comments:

Attention/concentration

Appropriate to context Focused Distracted Inattentive

Other:

Comments:


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Motor Activity

Appropriate to context Hyperactive

Fidgety Lethargic

Motor/muscle tic(s) Restless

Repetitive acts

Other:

Comments:

Speech

Appropriate forage/development

Slurred Slowed

Mumbling Rapid

Pressured Soft

Tangential Impoverished

Other:

Comments:

Eye Contact

Appropriate to context Intense

Avoidant Fleeting

Intense/Unwavering Sporadic

Other:

Comments:

Affect (observed)

Appropriate to context Congruent Incongruent

Fearful Anxious Sad

Apathetic Flat Constricted

Labile Euphoric

Withdrawn Agitated

Other:

Comments:


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Mood (experienced)

Appropriate to context Depressed

Elevated Anxious

Irritable Labile

Hopeless

Other:

Comments:

Thought Process

Unremarkable Coherent

Incoherent Tangential

Circumstantial Loose association

Confused

Other:

Comments:

Thought Content

Appropriate for age/development Ideas of reference Paranoid Flight of ideas

Other:

Judgment: Appropriate for age/development Impaired

Insight: Good Average

Poor Denies/minimized

Blames others Limited abstract reasoning skills

Comments:

Perception

Appropriate for age/development Derealization Depersonalization

Other:

Hallucinations: Auditory Visual Tactile Olfactory

Delusions: Grandiose Paranoid

Other:

Comments:


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Behavior (describe in comments)

Appropriate toage/development

Self-harm Impulsive

Aggressive – physical Aggressive – verbal

Bizarre

Other:

Comments:

Cognitive Concerns

Appropriate toage/development

Comprehension Short term memory

Long term memory I/DD

Other:

Comments:

CALOCUS/LOCUS

CALOCUS Level of Care Recommendation (For children only—ages 6 and up)

Dimension I: Risk of Harm

Dimension II: Functional Status

Dimension III: Co-Morbidity

Dimension IVA: Recovery Environment “Stress”

Dimension IVB: Recovery Environment “Support”

Dimension V: Resiliency & Treatment History

Dimension VI A: Acceptance & Engagement (Child/Adolescent) Dimension VI B: Acceptance & Engagement (parent/caretaker) Total Score (On IV and VI, use only the higher score of A or B to total)

Level of Care N/A

Alternate Level Recommended

Reason:


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Additional Assessment Scores/Results (Any standardized measures used)

Name of screener/tool Outcome

Diagnoses (From DSM-5; include the full name and ICD-10 code for each; include known behavioral and physical health diagnoses.)


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Summary, Case Formulation, and Recommendations Summary and Case Formulation (Summary of presenting problems, life domains, screening tools, diagnosis and justification of diagnosis, readiness for change, etc.)

Recommendations (i.e., Additional assessments, services, supports, or treatment based on CCA; interventions recommended to address factors contributing to behavior/symptoms. Consider clinical services and/or non-paid supports needed for child and/or adult caregiver, parenting and caregiving strategies, safety planning, educational setting recommendations, social/recreational activity recommendations, medical assessment/coordination, etc.)

Service Recommendations (other recommendations listed above) (Note: If not familiar with the criteria for some of the services below, in the “other” describe the treatment elements clinically indicated; ex. In-home services, crisis response availability, family skill development.)

Trauma-focused cognitivebehavioral therapy (TF-CBT)

Family therapyMedication management Day treatmentMultisystemic therapy Residential Level I-Family Type Residential Level II-Family Type Residential Level III-Group Home Psychological evaluation

Substance Abuse IntensiveOutpatient Program (SAIOP)

Family Centered Treatment (FCT) High Fidelity Wraparound Individual therapy Group therapy Respite Intensive In-Home services Supported Employment (16 and up) Residential Level II-Program Type

Residential Level II-Family Type(MH/IDD)

Psychiatric residential treatmentfacility

Parent assessment Detox In Home Therapy Services (IHTS) Trawnsitional Living (b)(3)

Other:


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Justification of Service Recommendations (Summary of assessment results that support the need for the recommended service(s)/level of care; cite how specific criteria for the level of care noted above is met for the member; for enhanced services, explain why lower levels of treatment were determined not to be appropriate.)

Signatures and Dates

Signature and credentials of clinician completing assessment Date

Comprehensive Clinical Assessment - Cardinal Innovations

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