Needs Assessment Form Adult & Adolescent Behavioral Health
Please provide as much detail as possible so that we can accurately assess your current situation. If you have already compiled information that we are requesting (for example, medication history), please attach it to this form and proceed to the next section. If a question does not apply to you, mark with a “NA” for “not applicable.”
If you feel that you are in danger to yourself or others, or are gravely disabled, go to the nearest emergency room immediately or call 911.
Helpful patient information to gather prior to completing this form: • Primary and secondary care physician’s name and contact information
• Insurance card(s) • Emergency contact information
• Medical history (physical health) • Psychiatric care history • Medication history
How to submit this form when complete: Email:
[email protected]
OR
Fax: 651-259-9790
OR
Mail/In Person: 7616 Currell Blvd #100 Woodbury, MN 55125
Complete This Form Electronically. Forms can be filled out, saved and viewed on a PC or Mac. For best results with typing and saving your information, please use Adobe Acrobat Reader DC. You can download a free version from acrobat.adobe.com. When completing electronically, you must save a copy of the form to your computer using a different filename before filling out and submitting.
We recommend you print a copy of the form before submitting it for your records and to ensure no information is lost in the saving process. If you experience trouble using the form electronically, please print the form and mail, fax or drop it off at our office. Forms should not be completed or saved and viewed using an iPad or iPhone device.
Typed responses are preferred for legibility. If completing by hand, please use black ink. Name of person completing this form and relationship to patient Date How did you learn about Aris Clinic? Physician
Therapist
School
Friend Other
Who Referred You: Treatment Interest: Psychiatry Clinic Appointment
Intensive Outpatient Program (IOP)
Child & Adolescent Only
Communication Needs (such as hearing impairment or non-English speaking patient or family member(s))
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Needs Assessment Form Adult & Adolescent Behavioral Health
1. CONTACT INFORMATION PATIENT Patient Name
Date of Birth
Gender (Biological)
Age
(Identifies As)
Race
Occupation Employer Address City
State
Zip
Home Phone
Cell Phone
Email Primary Physician and/or Clinic Date Last Seen
Phone Number Date of Last Labs Drawn
Pharmacy Name Patient is:
Phone Number
Married Unmarried Separated Divorced Widowed
SPOUSE/PARTNER Spouse/Partner Name
Date of Birth
Relationship to Patient
Occupation
Employer Same address as patient Address City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
Preferred Communication Method Is spouse/partner the financial guarantor for patient?
No
Yes
If financial guarantor, please provide social security number
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Needs Assessment Form Adult & Adolescent Behavioral Health
2. EMERGENCY CONTACTS – To be contacted in an emergency, please list at least one other contact
Name
Relationship to Patient
Address City
State
Home Phone
Cell Phone
Zip
Work Phone
Name
Relationship to Patient
Address City
State
Home Phone
Cell Phone
Zip
Work Phone
Name
Relationship to Patient
Address City
State
Home Phone
Cell Phone
Zip
Work Phone
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Needs Assessment Form Adult & Adolescent Behavioral Health
3. PATIENT INSURANCE INFORMATION PRIMARY INSURANCE Insurance Carrier
Insurance Phone Number
Policy #
Group #
Policy Holder Name Date of Birth
Relationship to Patient
Please attach a copy of patient’s insurance card(s) (front and back) SECONDARY INSURANCE (if applicable) Insurance Carrier
Insurance Phone Number
Policy #
Group #
Policy Holder Name Date of Birth
Relationship to Patient
Please attach a copy of patient’s insurance card(s) (front and back)
4. PHARMACY CONTACT INFORMATION Pharmacy Name Phone Location Do you prefer:
mail order
3 month supply
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Needs Assessment Form Adult & Adolescent Behavioral Health
5. PATIENT’S CURRENT PROBLEM(S) What difficulties are you having that have caused you to seek help?
When did these difficulties begin? How have they changed over time?
List all previous diagnoses you have received:
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Needs Assessment Form Adult & Adolescent Behavioral Health
6. PATIENT’S CURRENT GENERAL MEDICAL HISTORY A. Please check all health diagnoses: Hypertension
Diabetes – Type 1
Seizures
Thyroid
Diabetes – Type 2
Head Injury
Blackouts/Loss of Consciousness
B. Please check all health symptoms that apply to you currently: General
Ears/Nose/Throat
GenitoUrinary
Neurological
Allergies (to medication)
Congestion
Hesitancy
Movements
Allergies (other)
Retention
Seizure
Appetite/eating disorder
Headache
Menses
Tremor
Fatigue
Ringing
Sexual
Weakness
Injuries
Eyes
Hematological
Respiratory
Poor sleep
Blurry
Anemia
Cough
Sensory Issues
Dry
Bleeding
Surgeries
Flashes
Bruising
Wheezing
Weight
Pain
Nodes
Skin
Cardiovascular
Endocrine
Immunologic
Dry
Sweating
Congested
Dizziness
Thirst
Hives
Itching
Leg cramps
Too cold
Infections
Rashes
Swollen feet
Too warm
Rashes
Chest pain
Dry Mouth
Gastrointestinal
Musculoskeletal
Constipation
Aches
Diarrhea
Injury
Heartburn
Stiffness
Nausea
Swelling
Shortness of breath
Hair loss
Please describe the checked symptoms:
Other diagnoses, conditions, injuries, serious illnesses or additional details you wish to provide:
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Needs Assessment Form Adult & Adolescent Behavioral Health
7. PATIENT’S PAST OR CURRENT PSYCHIATRIC TREATMENT Therapist / Psychologist, Psychiatrist / CNP / Nurse Practitioner (Other than primary doctor who prescribed medications), Inpatient or ER Hospitalizations, Partial Hospitalization / Day Treatment, Occupational Therapy, Case Manager / County Case Workers, Other Providers Not Listed Above.
Provider Type
Provider Name / Facility
Approximate Start/End of Care Dates
Example: Therapist
Dr. Jane Doe / Clinic Name
MM/YY to MM/YY
Experience was Positive (+) or Negative (-)
Received Testing (yes) or (no)
Testing Completed (Type)
+
Yes
Test Name
8. PATIENT’S PAST OR CURRENT CHEMICAL DEPENDENCE TREATMENT
Age of First Use
Amount per day / per week Drugs or Drinks/Shots or Tobacco or Caffeine
Example: 15
2X’s / day - Caffeine
Experienced Blackouts (yes) or (no)
No
Detox
Input/ Output
No
input
Legal Problems Due to Chemical Dependence (yes) or (no)
No
DUI (yes) or (no)
No
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Needs Assessment Form Adult & Adolescent Behavioral Health
9. PATIENT’S CURRENT MEDICATIONS (Include all prescription, over-the-counter, herbal remedies, etc.) The following section will ask you to list past medications. Current Medications (NAME / DOSAGE)
When Started
Doctor /Prescriber
Positive/Negative Effects or None
10. EMPLOYMENT AND SOCIAL INFORMATION Highest level of education: Name of College
High School
Undergraduate
Graduate Graduation Date
Employer Position/Title
Length of Employment
Hobbies/Interests:
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Needs Assessment Form Adult & Adolescent Behavioral Health
11. PATIENT’S PAST TRIAL MEDICATIONS (Include all prescription, over-the-counter, herbal remedies, etc.) Past Medications (NAME / DOSAGE)
When Started
When Ended
Doctor / Prescriber
Positive / Negative Effects or None
12. PATIENT’S ALLERGY HISTORY Allergic to
Age at Reaction
Type of Reaction
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Needs Assessment Form Adult & Adolescent Behavioral Health
13. FAMILY COMPOSITION AND RELATIONSHIPS List the names of everyone who lives at the primary home: Name
Relation (Mother, Father, etc) Age
Date of Birth
List the names of everyone who lives at the additional home setting: Name
Relation (Mother, Father, etc) Age
Date of Birth
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Needs Assessment Form Adult & Adolescent Behavioral Health
13. FAMILY COMPOSITION AND RELATIONSHIPS (cont.) Parents:
Married
Unmarried
Were you adopted?
No
Separated
Yes
Divorced
If so, describe any unique circumstances with the adoption:
Describe any major health concerns of parents, grandparents, siblings:
Do you have children?
No
Yes
If yes, name(s) and age(s):
Major health concerns with children?
What supports are available to you in times of stress (extended family, friends, community or faith organizations, other therapists or therapies)?
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Needs Assessment Form Adult & Adolescent Behavioral Health
14. PATIENT’S DEVELOPMENTAL HISTORY If any of the following occurred, note the age: Bedwetting (after age 6)
Repeating other’s speech
Ignored people or other children
Nightmares or night terrors
Excessive anxiety (separation, when leaving home)
Odd movements
Nonsense speech or made-up words
Head-banging
Poor pronunciation
Repeating behaviors (twirling in circles, lining up toys)
Withdrawn
15. FAMILY PSYCHIATRIC HISTORY Have any immediate or extended family members needed help for emotional, behavioral, psychiatric or neurological problems or other serious medical problems? Check all that apply. Do NOT include yourself. Illness
Relationship to Patient
Medications Used
ADD/ADHD Alcoholism Anxiety Disorders Bipolar Disorders Depression Eating Disorders Learning Disorders Obsessive Compulsive Disorder Oppositional Defiant Disorder Personality Disorders Schizophrenia Seizures/Epilepsy Self-Harm Behaviors Substance Abuse Suicidal Behavior Tourette’s Other: Revised 12.01.16
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Needs Assessment Form Adult & Adolescent Behavioral Health
16. PATIENT HISTORY AND SIGNIFICANT LIFE EVENTS Please check all that apply to your history:
Racial identity issues
Self-injury
Suicidal actions
Please describe the checked item(s):
Were you exposed to, or a victim of, any type of abuse? Emotional
Please describe type, by whom, duration:
Physical Sexual Verbal Other: Please check all that apply to your history:
Break-up of a major relationship (patient)
Moves
Change in family’s financial status/employment
Terminal illness in the family
Death in the family/other losses
Witness to traumatic event(s)?
Divorce or separation
Please describe the checked item(s):
Are there any significant events that have occurred in your upbringing that would be important for us to know in working with you (fighting, abuse, chemical dependency, etc.)?
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Needs Assessment Form Adult & Adolescent Behavioral Health
17. OTHER List any other information you feel is important for us to know:
List questions you would like answered at this point, if possible:
How to submit this form when complete: Email:
[email protected]
OR
Fax: 651-259-9790
OR
Mail/In Person: 7616 Currell Blvd #100 Woodbury, MN 55125
Stay Informed Would you like to learn more about behavioral health? Email
[email protected] to begin receiving our e-newsletter. Stay connected with Aris via social media:
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