Client Information Date -Month -DayYearDate Picker Icon First Name* Last Name* DOB* Social Security # MA # Email Phone Number* Primary Physician Name Physician Address Phone Number Marital Status MarriedSingleDivorceWidow Veteran Status VeteranNon-Veteran Referring Agency/Therapist Referring Agency* Therapist* Credentials* Therapist NPI #* Email Adders* Fax Number Phone Number* DSM-5 Diagnosis* Diagnosis given by:* Credentials of diagnosing professional:* Length of time in treatment:* Reason for Referral (check all that apply)* Medical/SomaticSexual AbusePhysical or Emotional AbuseLegal/IncarcerationSocial/InterpersonalMedication ComplianceSubstance Abuse, client or familySchool Problems/SuspensionSuicidal/Homicidal RiskMedication MonitoringFinancial DifficultyAt Risk of Out-Of-Home PlacementCoping Skills PRP Services Requested (check all that apply)* Diagnostic InterviewSelf-Care TrainingEmployment Development TrainingSocial Skills DevelopmentCrisis InterventionAnger ManagementJob CoachingFamily SupportLife Skills TrainingHousing SupportOther Symptoms and Behaviors/Risk Behaviors (check all that apply):* Anxiety/PanicAttachment ProblemsTruancyIrritableSelf-Care DeficitVerbal AggressionProperty DestructionOppositional DefiantObsessions/CompulsionsSeparation ProblemsHyperactiveImpulsiveStealingPhysical AggressionSelf-Injurious BehaviorSuicidal IdeationsDepressed MoodFire SettingTrauma-relatedHomicidal IdeationsSexually InappropriateHopeless/HelplessRunning AwayLying/ManipulativeSocial/WithdrawalInsomniaOther Psychological & Environmental Problems (check all that apply)* Educational FinancialLegal System/CrimeHousingPrimary Support GroupOccupationalPsychologicalSocial EnvironmentAccess to Health CareNone Is the client on any medication? YesNo If yes, list all medications: Do you have a history of alcohol and/or substance abuse? YesNo If yes, Has the using created problematic situations in your life? Would you like information on treatment options? YesNo Why is on going therapy treatment not sufficient to address concerns?* 0/0 Back Next FUNCTIONING CRITERIA Does the participant have impairments related to the Priority Population diagnosis in three or more of the functional areas listed below? (At least 3 are required) To understand what is being requested for each of the functional impairments below, a generalizedexample of a response is provided here:1. Symptom of Priority Population diagnosis: Paranoia2. Impairment impacting Functioning: Paranoia results in being suspicious of others.3. Example of impaired function: Last week he would not get on the bus because he thought the driver was out toget him. He started yelling at the bus driver. A. Does the participant have marked inability to establish or maintain competitive employment?* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* B. Does the participant have marked inability to perform instrumental activities of daily living (e.g. shopping,meal preparation, laundry, basic housekeeping, medication management, transportation, and moneymanagement)?* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* C. Does the participant have marked inability to establish/maintain a personal support system?* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* D. Does participant have deficiencies of concentration/persistence/pace leading to failure to complete tasks?* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* E. Is the participant unable to perform self-care (hygiene, grooming, nutrition, medical care, safety)* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* F. Does the participant have marked deficiencies in self-direction, shown by inability to plan, initiate, organize, andcarry out goal directed activities?* YesNo Describe the symptoms of this Priority Population diagnosis that affect the participant's functioning** Describe how, specifically, these symptoms impair the participant's functioning** Provide specific concrete examples of THIS participant's impaired function* Referred by signature* Supervisor signature required if referred by LMSW credentials: Submit Should be Empty:
