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Comprehensive/Psychosocial Assessment
Client: ; Parent/Guardian:
Date: ; Time: ; 15 minutes; Billing Code: 90791 In-Office
DATA/DESCRIPTION:
Identifying Information:
Social/Family History (place of birth, family of origin, current family/relationship, relevant history):
Trauma/Abuse History:
Military/Veterans Status
Cultural/Ethnic/Spiritual/Religious Beliefs
Strengths/Resources:
ASSESSMENT/MENTAL STATUS:
Suicidal Ideations: None; Plan: N/A; Intent: N/A; Means: N/A
Notes:
Suicide Attempts/History:
Homicidal Ideations: None; Plan: N/A; Intent: N/A; Means: N/A
Notes:
Hallucinations: No; Described as:
Affect: Appropriate
Appearance: Well groomed
Eye Contact: Hesitant
Mood: Depressed and Anxious
Behavior: Agitated
Approach: Calm
Thought Content: No noted thought disorder
Memory: WNL
DPBH
Orientation: X3
Insight: Fair
Judgment: Good
Speech: WNL;
Language: Appropriate
Other:
Additional Mental Status Comments (If applicable): No access to firearms.
DIAGNOSTIC IMPRESSIONS:
Primary Diagnosis: (include code and description):