SAMPLEINITIALEVALUATIONTEMPLATE

I.DemographicInformation
Date:________________

Name:________________________________________________________________________________

Address:______________________________________________________________________________
Phone(Home/Cell):______________________
Phone(Work):

_____________________
DateofBirth:_______________________ SocialSecurity#:

____________________
Guardianship(forchildrenandadultswhenapplicable):

___________________________
MaritalStatus:

FamilyMembers
Name

Age
Gender

Relationship
_________________________________________________________________________________________
_____________________________________________________________________________________

Employer:____________________________Occupation:_____

_______________
School(forchildren,andadultswhenapplicable):

________________

II.EmergencyContactInformation

NameofEmergencyContact
Name:_________________________Phone:1.________________________2.______________________
RelationshiptoPatient:__________________________________
______________________

CurrentProviders
PrimaryMedicalPractitioner:_____________________________Phone:___________________________
Patientdoes____/doesnot____givepermissiontocontactprovider.(Ifpatientdoesgivepermission,please
ensureacopyofthereleaseforminthemedicalrecord.)

OtherBehaviorHealthSpecialistsorConsultants
Specialist:______________________________________________________________________________
Phone:______________________________
Patientdoes____/doesnot____givepermissiontocontactprovider.(Ifpatientdoesgivepermission,please
ensureacopyofthereleaseforminthemedicalrecord.)

III.PresentingProblem(includeonset,duration,intensity)
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________

PrecipitatingEvent(whytreatmentnow):
_______________________________________________________________________________________
_______________________________________________________________________________________

TargetSymptoms:

Frequency/Duration

DegreeofImpairment
Symptom#1:______________________________________________________________________
Symptom#2:______________________________________________________________________
Symptom#3:______________________________________________________________________
Symptom#4:______________________________________________________________________

IV.MentalStatus(circleappropriateitems)

Orientation:PersonPlaceTime
Affect:AppropriateInappropriateSadAngryAnxiousRestrictedLabileFlatExpansive

Mood:NormalEuthymicDepressedIrritableAngryEuphoric(describedetailsbelow)
ThoughtContent:
Obsessionsdescribe:
_____________________________________________________________________________
Delusions(specifyandcomment):
_____________________________________________________________________________
Hallucinations(specifyandcomment):
_____________________________________________________________________________

ThoughtProcesses:Logical CoherentGoaldirectedDetailedTangentialCircumstantiallllogicalLooseness
ofAssociationsDisorganizedFlightofIdeasPerseverationBlocking

Patientname:____________________________________________

Speech:
Normal

Slurred
Slow RapidPressured
Loud
Motor:
Normal

Excessive
Slow
Other________
Intellect:
Average
Above
Below
Insight:
Present
PartiallyPresent
Impaired
Judgment: Intact
Impaired
ImpulseControl:

Adequate Impaired
Memory:
Immediate Recent
Remote
Concentration:

Intact
Impaired
Attention: Intact
Impaired
Behavior:
Appropriate Inappropriate(describe___________________________________________
Details/additionalcomments:
_________________________________________________________________________________________
_____________________________________________________________________________________

V.RiskAssessment

SuicidalIdeationcheck(X)allrelevantanddescribeallcheckeditemsincommentssection
None Thoughts Frequency Plan Intent Means Attempt Activeor Chronicor

noted

(only)

of
thoughts

passive

acute

Comments
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________________

HomicidalIdeationcheck(X)allrelevantanddescribeincommentssection
None Thoughts Frequency Plan Intent Means Attempt Activeor Chronicor
noted only
of
passive
acute
thoughts

Comments
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________________

VI.Medical/BehavioralHealthHistory

_________________________________________________________________________________________
_____________________________________________________________________________________

Allergies(adversereactionstomedications/food/etc.)
_________________________________________________________________________________________
_____________________________________________________________________________________

Medications
IsthemembercurrentlyprescribedBHmedication(s)?___Yes__No(Ifyespleaseindicatebelow)

A.CurrentBHMedicationsprescribed
(Includeprescribeddosages,datesofinitialprescriptionandrefills,andnameofdoctorprescribing
medicationandchecktoindicateifmemberisadherentwitheachmedication):
_________________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________________

WeretherisksandbenefitsofBHmedicationadherencediscussedwiththepatient?
_________________________________________________________________________________________
_____________________________________________________________________________________

B.Ismembertakingothermedications(prescribedoroverthecounter)orsupplements?Yes___No__(ifyes
pleaselistandindicatewhy).
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________

PastPsychiatricHistory(MentalHealthandChemicalDependency):

_________________________________________________________________________________________
_____________________________________________________________________________________

PsychiatricHospitalizations:
_________________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________________

PriorOutpatientTherapy(includepreviouspractitioners,datesoftreatment,previoustreatment
interventions,responsetotreatmentinterventions(includingresponsestomedications),andthesource(s)
ofclinicaldatacollected):
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________

Patientname:__________________________________________________________________________

Resultsofrecentlabtestsandconsultationreports(Forphysiciansonlyandonlywhereapplicable):
_______________________________________________________________________________________
_______________________________________________________________________________________
FamilyMentalHealthorChemicalDependencyHistory:
_________________________________________________________________________________________
_______________________________________________________________________________________
VII.PsychosocialInformation
SupportSystems:

School/WorkLife:

LegalHistory:
_________________________________________________________________________________________
_____________________________________________________________________________________

VIII.SubstanceAbuseHistory(completeforallpatientsage12andover)
Substance
Amount
Frequency Duration
FirstUse
LastUse
Comments
Caffeine

Tobacco

Alcohol

Marijuana

Opioids/

Narcotics
Amphetamines

Cocaine

Hallucinogens

Others:

FORCHILDRENANDADOLESCENTS:
DevelopmentalHistory(developmentalmilestonesmetearly,late,normal):

___________________________

RiskFactors:
____DomesticViolence
____ChildAbuse
____Priorbehavioralhealthinpatientadmissions
____SexualAbuse
____Historyofmultiplebehavioraldiagnosis
____EatingDisorder
____Suicidal/homicidalideation

____Other(describe)

DiagnosticImpression:

AxisI:

AxisII:

AxisIII:

AxisIV:
________Mild
________Moderate _______Severe
NatureofStressors:__Family____School___Work___Health___Other
AxisV:

CurrentGAF:___________
HighestGAF:___________

Pleasenote:Aetnacreatedthisdocumentasasampletooltoassistprovidersindocumentation.Aetnadoesnotrequiretheuseofthisdocument,norarewe
collectingtheinformationcontainedherein.

04/13

SAMPLETREATMENTPLANTEMPLATE

Patientsname:_____________________________________________________________

Alltreatmentgoalsmustbeobjectiveandmeasurable,withestimatedtimeframesforcompletion.The
treatmentplanistobedevelopedwiththepatient,andthepatientsunderstandingofthetreatmentplanis
tobedocumentedinthemedicalrecord.
TreatmentGoals[aftereachitemselected,indicateoutcomemeasures(i.e.asevidencedby)]
____ReduceRiskFactors:___________________________________________
____ReduceMajorSymptoms:_________________________________________
____DecreaseFunctionalImpairments:__________________________________
____DevelopCopingStrategiestoDealwithStress:________________________
____Stabilize(shortterm)Crisis:________________________________________
____Maintain(longterm)StabilizationofSymptoms:_________________________
____Medicationreferralto:_____________________________________________

PlannedInterventionsPatientParticipation(mustbeconsistentwithtreatmentgoals):
___AssertivenessTraining
___ProblemSolvingSkillsTraining
___AngerManagement
___SolutionFocusedTechniques
___AffectIdentificationandExpression
___StressManagement
___CognitiveRestructuring
___SupportiveTherapy
___CommunicationTraining
___Self/OtherBoundariesTraining
___GriefWork
___DecisionOptionExploration
___Imagery/RelaxationTraining
___PatternIdentificationandInterruption
___ParentTraining
____MedicationManagement
___EngageSignificantOthersinTreatment:________________________________________________
___FacilitateDecisionMakingRegarding:__________________________________________________
___Monitor:__________________________________________________________________________
___TeachSkillsof:________________________________________________________
___Educateregarding:_____________________________________________________
___AssignReadings:__________________________________________________________________
___AssignTasksof:__________________________________________________________________
___ReferralsPlanned:_____________________________________________________
___PreventiveStrategies:___________________________________________________
___Obstaclestochange:____________________________________________________

MytherapistandIhavedevelopedthisplantogether,andIaminagreementtoworkingontheseissuesand
goals.Iunderstandthetreatmentgoalsthatweredevelopedformytreatment.
PatientsSignature_______________________________________________Date_____________
ProvidersSignature______________________________________________Date_____________

Pleasenote:Aetnacreatedthisdocumentasasampletooltoassistprovidersindocumentation.Aetnadoesnotrequiretheuseofthisdocument,norarewe
collectingtheinformationcontainedherein.

04/13

SAMPLEDISCHARGESUMMARYTEMPLATE
Mustbecompletedwithin60daysfromlastvisit

Patientsname:______________________________________________

DateofDischarge:__________________;dateoflastcontact:_______________(telephonicorvisit?)

ReasonforTermination(waspatientinagreementwithterminationatthistime?):
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________
Ifpatientdidnotreturnforscheduledappointment,listattempt(s)madetocontactpatienttoreschedule?
_________________________________________________________________________________________
_____________________________________________________________________________________

PatientConditionatTermination(werealltreatmentgoalsreached?):
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________

DischargeMedications:
_______________________________________________________________________________________

FinalDSMIVAxisI:________________________________
AxisII:_______________________________
AxisIII:______________________________
AxisIV:______________________________
AxisV:_______________________________

ReferralOptionsGiven(iftreatmentgoalswerenotmet,appropriatereferralsmustbemade)
1) ____________________________________________________________________________________
2) ____________________________________________________________________________________

TreatmentRecordDocumentsPreventiveServicesasappropriate(forexample):
_____RelapsePrevention

_____StressManagement

________________
_____Other(list):_____________________________________________________________________

Ifpatientbecamehomicidal,suicidal,orunabletoconductactivitiesofdailylivingduringcourseof
treatment,waspatientreferredtoappropriatelevelofcare?(Explain):

_________________________________________________________________

________________________________________________________________________

Signature:______________________________________________________Date:__________________

Pleasenote:Aetnacreatedthisdocumentasasampletooltoassistprovidersindocumentation.Aetnadoesnotrequiretheuseofthisdocument,norarewe
collectingtheinformationcontainedherein.

04/13