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(page 1 of 2)
Clinical Assessment
Instructions: Complete the Clincial Assessment during or after the first EAP session with a Magellan client. The completed assessment is to be filed in the client's clinical record.
CLIENT NAME:
CASE#:
(located on the EAP billing form)
PRECIPITATING EVENT:
PSYCHOLOGICAL/EMOTIONAL SYMPTOMS and MENTAL STATUS Current Signs and Symptoms: 0=None 1=Mild 2=Moderate 3=Severe Depressed Mood Appetite Disturbance Sleep Disturbance Elimination Disturbance Low Energy Psychomotor Retardation Agitation Lability Irritability
Organicity Indicators: Oriented x 3 Impaired Memory Other Cognitive Impairment Specify: Delusions Hallucinations Aggressive Behaviors Conduct Problems Oppositional Behavior Sexual Dysfunction
Yes Yes Yes 0 0 0 0 0 0
1 1 1 1 1 1
No No No 2 2 2 2 2 2
3 3 3 3 3 3
RISK ASSESSMENT. Check any risk that has occurred in the past three (3) months. Elaborate on any positive findings. Severity 0 1 2 3 4 5
Suicidal Risk None Ideation D Intent D Plan D Means D* Attempt D
* Includes client’s access to guns
Homicidal Risk None Ideation Intent Plan Means* Attempt
Abuse: physical/sexual Victim None Ideation Intent Plan Means * Attempt
D Complete
Domestic Violence
Perpetrator
Victim Perpetrator None Verbal Abuse D Emotional Abuse D Physical/sexual abuse D Medical attention/ER D Life threatening D
Depression Screening and results
Threat of Violence (TOV) LEVEL. Check applicable level. Levels 3-5 require that you contact a Magellan EAP Consultant within 48 hours 1- Assessed; no indicators 4- Active threat of violence exists
2- Possible threat mentioned; no current danger 5- Client is dangerous to self/others
3- Threat made; possibility of violent action exists
Comments:
ENVIRONMENTAL, HOME, AND WORK SITUATION; SOCIAL AND PEER SUPPORTS:
RELEVANT SOCIAL HISTORY:
(circle letter left for every statement that applies.) Impact of substance/alcohol use: (Check eachatstatement that “yes” applies.) U N C O P E
“In the past year, have you ever drunk or used drugs more than you meant to?” or “Have you spent more time drinking or using than you intended to?” “Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?” “Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?” “Has anyone objected to your drinking or drug use?” “Have you ever found yourself preoccupied with wanting to use alcohol or drugs?” “Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger or boredom?”
Two or more checked responses indicate abuse or dependence. Complete the Substance Abuse/Chemical Dependency Assessment Form: None Noted Current suspected DSM diagnosis of substance abuse, or
Current suspected DSM diagnosis of substance dependence Uncope Norman G. Hoffman, Ph.D.
FAMILY HISTORY OF CHEMICAL DEPENDENCE/SUBSTANCE ABUSE OR MENTAL ILLNESS:
PREVIOUS TREATMENT HISTORY: LAST VISIT TO MD:
DATE:
CURRENT MEDICAL CONDITIONS: CURRENT MEDICATIONS:
DETERIORATION IN JOB / SCHOOL PERFORMANCE DUE TO THE PROBLEM: Attendance Erratic behavior
Conflict with supervisor Accidents/Safety Violations
CLIENT STRENGTHS / LIMITATIONS 1. Bright, learns quickly 2. Insightful/self aware 3. Relates well to others 4. Good social support system 5. Satisfied w/ job 6. Satisfied w/ job performance 7. Hobbies or recreational activity 8. Marital satisfaction 9. Motivated to change 10. Cultural / community involvement 11. Spiritual focus 12. Special needs 13. Other
