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CWS REHABILITATION INITIAL ASSESSMENT State Form 54573 (1-11)
FAMILY & SOCIAL SERVICES ADMINISTRATION RICHMOND STATE HOSPITAL
GENERAL Client Name: (need full name at time of admission)
Admission Date (month, day, year):
Avatar Chart Number:
Date of Assessment (month, day, year):
Time of Assessment:
Assessment Type:
Initial
Initial Reassessment
Annual
AM
PM
Annual Reassessment
Assessing Clinician: Assessing Clinician 2: Supervising Clinician: Notification Comments:
Draft / Pending Approval / Final:
Draft
Pending Approval
Final
Primary Language: (Aliased in from PM side) Preferred Language: Arabic French Japanese Sign Language
Interpreter Used:
Chinese German Other Spanish
No
English Italian Russian Unknown
Yes
Language Comments:
Informant Type: Another provider Family / Significant other Legal Representative
Client Gatekeeper Records from previous admission
Current Assessments / Evaluations Justice system Other (specify)
Informant Comments: (Identify specific re: source of information / informants - assessed - reliability, validity. Informant comments re: reason for admission or events leading up to admission, symptoms described / reported, etc.).
LEISURE Leisure Interest Survey
Leisure Interest Active games / Sports Activities with peers Arts and Crafts Fitness / Health
Hobbies and Clubs Music Outdoor Activities Quiet / Solitary activities
Spirituality TV/Video games /Computers Other (specify) _____________________
Leisure Comments:
Do You Have a Special Interest or Talent?
Do You Wish to Share This With Others?
No
Yes
Special Interest Comments:
What is Your Favorite Activity?
How Do You Spend Your Free Time? With others What Activities Do You Do When You are By Yourself?
By yourself
Depends on situation
Unknown
Activity Comments: (Clinician assessment - include recommendations)
How Do You Usually React in Group Situations? Join in Quiet and watch
Leave group Unknown
Listen for a while, then join in Other (specify) _____________________________
Group Situation Comments:
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LEISURE (continued) Barriers That Restrict Involvement in Activities:
List Programs / Activities Participated in Over Past Year: (Client’s perspective) (Please include classes, services, outpatient programs, previous programs at other hospitals, and/or treatments.)
What Programs / Activities Have Helped You? (Client’s perspective) (Please include classes, services, outpatient programs, previous progress at other hospitals, and/or treatments.)
What Programs / Activities Do You Think Will Help Your Recovery While You Are Here? (Client’s perspective) (Could obtain answer to this question via “what brought you to the hospital” or leisure education/awareness questions as these may trigger response on what they need to change and how hospital can help.)
What are Your Goals Over the Next Year? (Client’s perspective)
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LEARNING / EDUCATION Highest Level of Education Completed: 1 year college completed 2 years college completed 3 years college completed 4 + years college completed 4 yrs college completed
(If patient states otherwise, note difference in information in the comments field.)
Associate’s Bachelor’s Doctorate GED *(Grade 1-12) Indicate highest level ____ ______________________________________
Master’s Never attended school Pre-School / Kindergarten Special Ed / Emotional handicap Trade or Business college Unknown
Gifted Other
Home schooled Unknown
Education Program Type: Special education Regular
DIPLOMA:
Special Education Type: Emotional disability Other
Learning disability Unknown
GED None
High school Other
College
Education Comments:
Are You Interested in Increasing Your Academic Skills or Working Toward Your GED?
No
Yes
Academic Skills / GED Comments:
No
Reading Ability: (Describe in comments how ability was assessed)
Reading Ability Comments: (Use standardized paragraph and address accordingly.)
4
Yes
Limited
LEARNING / EDUCATION (continued) No
Writing Ability: (Describe in comments how ability was assessed)
Yes
Limited
Writing Ability Comments: (Have client write name. Have client write sentence, ie “The weather today is…” Transpose client’s written statements into comment box. Indicate reason in inability.)
Client’s Ability to Learn / Motivation / Client’s Participation Ability to Learn No Obvious / Apparent impairments
Cognitive deficit
Unable to assess
Motivation to Learn Motivated
Unmotivated
Unable to assess
Participation in Assessment Process Good
Fair
Poor
Unable to participate
Learn / Motivation / Participation Comments: (Described above responses in detail)
Client’s Preferred Learning Style: Classroom setting Hearing information Small group setting
Demonstration Individual Video
Hands-on Reading information Other (specify) ________________________
Learning Style Comments:
Allen Cognitive Level: Name of Test / Results:
N/A
Allen Cognitive Level Score:
Total Score
5
VOCATIONAL No
Have You Worked in the Past?
Yes
None / NA
Unknown
List Past Employment:
Where Was Your Most Recent Job? What Type of Work Did You Do? How Long Were You There? Reason for Leaving: Employment Comments:
No
Do You Have Your Social Security Card?
Yes No
Are You Interested in Working During Your Stay?
Yes
Preferred Type of Work: Vocational Comments:
WELLNESS Wellness Indicators
Client Understands the Wellness Concept? Client Strives to be Physically Fit?
Good
Good
Fair
Client Initiates and Continues Physical Activities?
Client Practices Healthy Lifestyle? Client Participates in Fitness Activities? Client Ambulates without Difficulty? Use of Leisure Time:
Good
Good Good
Poor
Poor
Fair
Fair Fair
Wellness Comments:
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Unknown Poor
Poor Poor
Unknown Unknown
Poor Fair
Unknown Unknown
Fair
Fair Good
Poor Poor
Good
Good
Client Complies With Diet?
Fair
Unknown Unknown Unknown
WELLNESS (continued) Addictions
No
Past History of Addictions:
Yes
Denies
Unknown
Addiction Issues: Alcohol Gambling
Drugs Sexual
Exercise Tobacco
Food Other (specify) ___________
Other Addiction Issues:
Addiction Comments:
What Activities Do You Associate with Your Addiction?
What Activities Did You Have to Give Up Due to Your Addiction?
What Leisure Activities Have You Learned to Do Without the Use of a Substance?
COMMUNITY SKILLS Community Living Skills / Self-Care Skills Community Resources Utilized Community Center Mental Health Center Spiritual Center
Health Clubs Movie Theaters Support Groups
Library Parks and Recreation Other (specify) ______________
Malls Restaurants
Community Resources Comments:
Community Living Needs: Clothing care / Selection Money management Safety Time management
Grooming / Hygiene Nutritional / Meal planning Shopping Transportation
Community Living Comments:
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Home maintenance / Cleaning Resource utilization Survival skills Other (specify) ________________________
COMMUNITY SKILLS (continued) Social Functioning: Difficulty controlling emotions Difficulty interpreting others feelings Expresses feelings effectively Good communication skills Intrusive Lacks self esteem or self confidence Outgoing Self absorbed w/little regard for others Talks excessively Other (specify) _____________________________________________
Difficulty expressing feelings Draws unnecessary attention to self Expresses gratitude / Appreciation Impolite / Disrespectful Lack of personal boundaries Minimal effective communication skills Polite / Respectful Self confident / Self esteem Withdrawn
Social Functioning Comments:
No
Has Client Ever Volunteered?
Yes
Volunteer Activities Comments:
INTERVIEW OBSERVATIONS Appearance: Appears older than stated age Clean Excessive / Inappropriate make-up Poor grooming
Appears stated age Clothing inappropriate to season Malodorous Other (specify) _____________________
Appears younger than stated age Disheveled Neat
Appearance Comments:
Interview Behavior: Avoidant Hyperactive Mute Resistant Other (specify) ____________
Cooperative Hypervigilant Oppositional Self-injurious
Defiant Impulsive Pacing Verbally aggressive
Interview Behavior Comments:
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Destructive Intrusive Physically aggressive Withdrawn
INTERVIEW OBSERVATIONS (continued) Cognitive Functioning: Disoriented to person Disoriented to time Oriented / Alert Short attention span Unable to follow simple instructions
Confused Disoriented to place Easily distracted Preoccupied Thought process slowed Other (specify) ________________________________________
Cognitive Comments:
STRENGTHS / NEEDS and RECOMMENDATIONS Self Assessment
What Do You Think Your Strengths are?
What are You Most Proud of?
What Makes You Happy?
What Do You Think You Need to Improve On?
What Do You Think Your Barriers are?
What Do You Want to Do When You Leave the Hospital?
What is Important to You?
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STRENGTHS / NEEDS and RECOMMENDATIONS (continued) Strengths Assessed Strengths Assessed Adaptability Education / Intelligence Good social skills Hopeful / Optimistic Motivation Survival skills optimistic Other (specify) ________________________
Capacity of control Family / Community support High self esteem Independent self care skills Resourceful Use of hobbies / Leisure activities
Cooperative / Follows directions Good communication skills Honesty
Insight Source of income Work skills
Needs Needs Assessed Addiction education / Support Lack of family / Community support Limited education Low self esteem Poor coping skills Poor independent living skills Other (specify) ________________________
Anger issues Lack of insight Limited leisure interest Non-compliance Poor decision making Poor self-care
Strengths / Needs Comments:
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Easily frustrated Lack of interest Loss of hope / Pessimistic Poor concentration Poor health Poor social skills
STRENGTHS / NEEDS and RECOMMENDATIONS (continued) Summary and Recommendations
Clinical Summary: (Integration of all rehab clinical assessment factors that will identify strengths, goals, needs, limitations, barriers, and treatment recommendations to enable recovery and discharge.)
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STRENGTHS / NEEDS and RECOMMENDATIONS (continued) Rehab Recommended Areas of Focus: (Issues to be addressed by Rehab – needs to be considered in initial treatment plan. (Link for integrated treatment plan reports/development). Animal assisted therapy Community awareness / Resources Health / Wellness Money management / Budgeting Physical fitness Sports / Active games
Art therapy Crafts Independent living skills Music therapy Reality orientation Other (specify) ________________________
Communication / Social skills Education program / School Leisure education Orientation Sensory stimulation
Multi-Disciplinary Recommended Areas of Focus: Anger / Stress management Grief / Loss Mental health issues Sexual issues group Vocational training
Coping skills Individual therapy Recovery issues Spirituality WRAP
Dialectal Behavior Therapy Medication education Relaxation skills Substance abuse Other (specify) ________________________
Recommended Areas of Focus Comments:
Rehab Initial Areas of Focus: (Priority issues to be addressed/considered for initial treatment plan from Rehab.) (May include goals, objectives and treatment methods. (Link for integrated treatment plan report/development).
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