The 1915(c) Independent Behavioral Health Assessment form is a comprehensive document used to collect detailed information about a child or youth's demographic, behavioral health history, current and past medical conditions, legal status, family history, living situation, educational and employment status, social history, and more. It serves as a crucial tool in understanding the individual needs of children and youths seeking behavioral health services. If you’re looking to initiate or review behavioral health services for a child or youth, ensure the 1915(c) Assessment form is thoroughly filled out by clicking the button below.
In the realm of behavioral health assessment, the 1915(c) Independent Behavioral Health Assessment form serves as a comprehensive tool designed to capture an array of vital information about a child or youth's mental and physical health status, legal statuses, family history, and much more. It starts with demographic details including the child or youth's name, age, and other identifying information, ensuring that each assessment is person-centered and tailored to the individual's needs. The form delves into the behavioral health history, presenting problems, and relevant psychiatric history, allowing clinicians to understand the chief complaints and symptoms that are impacting the individual's daily life. Substance use history is also meticulously noted, recognizing the significant role that substance use may play in the individual's overall health and wellness. Physical health conditions are not overlooked, underscoring the integration of mental and physical health in comprehensive care planning. Legal status and family history are explored to provide context about the individual's life situation, which can be critical for crafting an effective support plan. Educational and employment status, along with social history and community integration, offer insight into the individual's daily functioning and social supports. The completion of this assessment includes a mental status examination to detail the individual's appearance, behavior, and cognitive functions. Additionally, a risk assessment is conducted to identify any potential for harm to self or others, which is paramount in planning for the individual's safety and well-being. The form culminates in a section dedicated to cultural and language preferences, ensuring that services are delivered in a manner respectful of and responsive to the individual’s cultural and linguistic needs. Finally, a summary and recommendations section allows the assessor to articulate their clinical impressions and propose a plan for treatment and support, highlighting the importance of this form in facilitating targeted, effective, and culturally competent care.
1915(C) INDEPENDENT BEHAVIORAL HEALTH ASSESSMENT
DEMOGRAPHIC INFORMATION
Child/Youth Name: (first, middle, last)
Assessment Date:
Age:
DOB:
Ethnicity:
Gender:
Gender Expression:
SSN:
Parent/Primary Caretaker Name: (first, middle, last)
Legal Guardian Name: (first, middle, last)
Is this person, the legal guardian?
□ Yes □ No (if not, enter information below)
Title/Department:
Phone Number:
BEHAVIORAL HEALTH HISTORY
I.CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health –in client/members’/caretaker’s own words/quoted.)
II. PRESENTING PROBLEM/RELEVANT HISTORY (Including client/member/caretaker/guardian reason for seeking services, precipitating factors, symptoms, behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and expectations.)
CURRENT BEHAVIORAL HEALTH PROVIDER NAME:
PHONE NUMBER:
III.PAST PSYCHIATRIC/PLACEMENT HISTORY (First onset of illness, past diagnostic and treatment history, medications, hospitalizations):
Prior Outpatient Mental Health Treatment: □ No; □ Yes;
Psychiatric Hospitalizations: □ No; □ Yes;
Detail:
Prior Residential/Out of Home Placement: □ No; □ Yes;
Additional History/Comments:
IV. SUBSTANCE USE HISTORY (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.)
Check any/all that apply in past 12 months:
□ Alcohol Use; □ Illegal Drug Use; □ Injected Drug Use ; □ Tobacco Product Use; □ Prescription Drug Misuse; □ Non-Prescription Drug (OTC) Misuse
□Alcohol and/or Drug Overdose; □ Alcohol and/or Drug Withdrawal; □ Problems caused by gambling; □ Trouble stopping any substance
□Other/Describe:
Substance Use Treatment History:
□ None; □ Outpatient;
□ Intensive Outpatient; □ Residential/Inpatient; □ Detox;
□ Other/Describe:
Hx of Drugs Used/Describe
SUBSTANCE TYPE
AGE OF
YEARS IN
DAYS IN
DAYS SINCE
AMOUNT
ROUTE OF ADMINISTRATION
Include all use in last 30 days.
1ST USE
LIFETIME
PAST 30
LAST USE
□ Oral; □ Nasal; □ Smoking; □ Non-IV Injxn; □ IV
PHYSICAL
V.CURRENT MEDICAL CONDITIONS (Check all that apply)
□ Pregnant
Due date:
Prenatal care:
□ None Reported
□ Congestive Heart Failure
□ Asthma
□ Seizure
□ Cancer
□ Underweight
□ High Blood Pressure
□ Stroke
□ Emphysema
□ Cirrhosis
□ Chronic Pain
□ Overweight
□ Heart Disease
□ Diabetes
□ Epilepsy
□ Digestive Problems
□ Thyroid Disease
□ Sexually Transmitted Dz.
VI.
CURRENT & PAST MEDICATIONS(Including non-psychotropic medications)
Medication Name
Dose
Freq.
Route
Current
COMMENTS (Reason Prescribed/Response, etc.)
□ Yes; □ No
VII.
ALLERGIES
□ No
Reported Drug
or Food Allergies;
1915(c) IA v.2 (5/7/2014)
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VIII.
PRIMARY CARE PHYSICIAN
NAME
PHONE
FAX
IX.
ADDITIONAL SIGNIFICANT MEDICAL HISTORY (Diagnosis, Hospitalizations, Surgery, labs values, status of conditions, etc.)
SOCIAL
X.LEGAL STATUS
Current Legal Status: □ None; □ Probation; □ Charges Pending; □ DCFS;
□OJJ; □ Other
Comment/Detail:
Past Legal Status: □ None; □ DCFS; □ OJJ; □ Other
XI.
FAMILY HISTORY (relationship status with relatives, family involvement in treatment, and living status of significant relatives):
Custodial Status: □ Independent Adult; □ Biologic Father; □ Biologic Mother; □ Joint Biologic Parents; □ Gov’t/Judicial; □ Other:
Adverse Circumstances in Family of Origin:
□ N/A; □ Poverty; □ Criminal Behavioral; □ Mental Illness; □ Substance Use; □ Abuse; □ Neglect;
□ Domestic Violence; □ Violence; □ Trauma; □ Other/Describe:
Summarize family history and child-rearing practices:
XII.
TRAUMA HISTORY
History of Trauma: □ None; □ Experienced; □ Witnessed; □ Abuse; □ Neglect; □ Violence; □ Sexual Assault;
Summarize trauma history:
XIII.
LIVING SITUATION (Current status and functioning)
a.Primary Residence: □ Parent/Guardian Home; □ Relative’s Home; □ Out of Home placement; □ Homeless; □ Other/Describe:
How long at current residence? Family/Household Composition:
b.Summarize current living situation:
XIV.
EDUCATIONAL/EMPLOYMENT STATUS
a.
Current Educational Placement/Employer:
Current or Highest Grade Completed/Degree:
Difficulties with Reading/Writing: □ No; □ Yes;
Estimated Literacy Level:
b. Summarize educational history and status:
.
XV.
SOCIAL HISTORY AND COMMUNITY INTEGRATION
a.Current status and functioning (Involvement in the community, social supports and activities, social barriers)
Does Client/Member feel supported by friends or family? □ Yes; □ No;
Recreational Activities: Self-Help Activities:
b.Summarize social and community involvement:
CURRENT STATUS
XVI.
MENTAL STATUS EXAMINATION
(Circle or Check all that apply.)
a. GENERAL APPEARANCE
□ Healthy; □As stated Age;
□ Older Than Stated Age; □ Young-looking;
□ Tattoos;
□ Disheveled; □ Unkempt;
□ Malodorous; □ Thin;
□ Overweight;
□Obese; □ Other/Describe:
b. BEHAVIOR & PSYCHOMOTOR ACTIVITY
□ Normal;
□ Overactive; □ Hypoactive;
□ Catatonia;
□ Tremor;
□ Tics; □ Combative;
c.
ATTITUDE □ Optimal;
□ Constructive; □ Motivated;
□ Obstructive; □ Adversarial;
□ Inaccessible;
□ Cooperative; □ Seductive; □ Defensive;
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□ Hostile;
□ Guarded;
□ Apathetic;
□ Evasive;
□ Other/Explain:
d. SPEECH
□ Spontaneous; □ Slow;
□ Impoverished;
□ Hesitant; □ Monotonous;
□ Soft/Whispered; □ Mumbled; □ Rapid;
□ Pressured; □ Verbose; □ Loud; □ Slurred; □ Impediment;
e.
MOOD:
□ Dysphoric;
□ Euthymic;
□ Expansive; □ Irritable;
□ Labile;
□ Elevated; □ Euphoric;
□ Ecstatic; □ Depressed; □ Grief/mourning;
□ Alexithymic; □ Elated;
□ Hypomanic;
□ Manic; □ Anxious; □ Tense;
f.
AFFECT
□ Appropriate;
□ Inappropriate; □ Blunted; □ Restricted;
□ Flat; □ Labile;
□ Tearful; □ Intense;
g. PERCEPTUAL DISTURBANCES □ None;
Hallucinations:
□ Auditory;
□ Visual;
□ Olfactory;
□ Tactile;
h. THOUGHT PROCESS
□ Logical/Coherent;
□ Incomprehensible;
□ Incoherent;
□ Flight of Ideas;
□ Loose Associations; □ Tangential;
□ Circumstantial;
□ Rambling;
□ Racing Thoughts;
□ Perseveration;
□ Thought Blocking;
□ Concrete;
i. THOUGHT CONTENT
□ Preoccupations;
□ Obsessions;
□ Compulsions;
□ Phobias;
□ Delusions;
□ Thought Broadcasting;
□ Thought Insertion;
□ Thought Withdrawal; □ Ideas of Reference;
□ Ideas of Influence;
j. SUICIDAL/HOMICIDAL IDEATION □ Suicidal Thoughts; □ Suicidal Attempts; □ Suicidal Intent; □ Suicidal Plans; □ History of Self-Injurious Behavior
□ Homicidal Thoughts; □ Homicidal Attempts;
□ Homicidal Intent;
□ Homicidal Plans;
k. SENSORIUM/COGNITION
□ Alert;
□ Lethargic; □ Somnolent;
□ Stuporous;
Oriented to: □ Person; □ Place; □ Time;
□ Situation;
□ Normal Concentration; □ Impaired Concentration;
l. MEMORY
Remote Memory: □ Normal; □ Impaired;
Recent Memory: □ Normal; □ Impaired; Immediate Recall:
□ Impaired
m. INTELLECTUAL FUNCTIONING (Estimate) □ Above Avg.; □ Normal/Avg.; □ Borderline;
Mental Retardation: □ Mild; □ Moderate;
□ Severe
n. JUDGMENT
□ Critical Judgment Intact; □ Impaired Judgment;
o. INSIGHT
□ True Emotional Insight;
□ Intellectual Insight; □ Some Awareness of Illness/symptoms; □ Impaired Insight; □ Denial;
p. IMPULSE CONTROL □ Able to Resist Impulses;
□ Recent Impulsive Behavior; □ Impaired Impulse Control; □ Compulsions;
XVII.
RISK ASSESSMENT: Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use,
criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc.
a. Risk of Harm to Self:
□ Prior Suicide Attempt;
□ Stated Plan/Intent; □ Access to means (weapons, pills, etc.);
□ Recent Loss;
□ Presence of Behavioral Cues (isolation, giving away possessions, rapid mood swings, etc.);
□ Family History of Suicide; □ Terminal Illness;
□ Substance Abuse; □ Marked lack of support; □ Psychosis;
□ Suicide of friend/acquaintance; □ Other/Describe:
b.
b. Risk of Harm to Others: □ Prior acts of violence; □ Destruction of property; □ Arrests for violence; □ Access to means (weapons);
□ Substance use; □ Physically abused as child; □ Was physically abusive as a child; □ Harms animals; □ Fire setting;
□ Angry mood/agitation;
□ Prior hospitalizations for danger to others; □ Psychosis/command hallucinations;
Client/Member Safety & Other Risk Factors: □ Feels unsafe in current living environment; □ Feels currently being
harmed/hurt/abused/threatened by someone; □ Engages in dangerous sexual behavior; □ Past involvement with Child or Adult Protective
Services; □ Relapse/decompensation triggers;
d.
□ Inappropriate sexual behaviors
□ Sex offender status
□ Pending sex offense charge
□ Report or Investigation □ Other: _
Additional Risk Factors
f.Describe recipient’s preferences and desires for addressing risk factors, including any Mental Health Advance Directives or plan of response to periods of decompensation/relapse (Ex. Resources recipient feels comfortable reaching out to for assistance in a crisis.):
XVIII. CULTURAL AND LANGUAGE PREFERENCES (Language, Customs/Values/Preferences)
a.Spiritual Beliefs/Preferences:
b.Cultural Beliefs/Preferences:
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XIX.
PRINCIPAL DIAGNOSES
AXIS I
AXIS II
AXIS III
AXIS IV
AXIS V
Current:
Highest Past Year:
XX.INTERPRETIVE SUMMARY: Briefly describe client/member’s global preferences/hopes for recovery, your clinical summary, and recommended treatments/assessments, level of care, duration.
a. Recommended Services: (Check all that apply.)
□ Family Therapy; □ Individual Therapy; □ Group Therapy; □ Alcohol/Drug Assessment;
Alcohol/ Drug Individual Therapy;
□ PSR;
□ CPST; □ Other/Describe:
b.Other Services/Linkages Needed: □ Vocational Services; □ Social Services; □ Educational Services; □ Medical Services/PCP; □ Self help Groups; □ Other/Describe:
c.Additional Comments:
SIGNATURE
PRINTED NAME OF ASSESSOR
LMHP STATUS
DATE
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When completing the 1915(c) Independent Behavioral Health Assessment form, it's crucial to approach it with the understanding that accurate and detailed information is vital. This form serves as a comprehensive overview of an individual's behavioral health needs, incorporating demographic information, health history, and more. By meticulously filling out this form, you contribute essential information that supports the evaluation and planning of appropriate behavioral health services. Below are the steps to ensure the form is completed correctly:
Following these steps will help ensure that the 1915(c) Independent Behavioral Health Assessment form is filled out comprehensively, providing a solid foundation for behavioral health service planning and support.
What is the purpose of the 1915(c) Independent Behavioral Health Assessment form?
The 1915(c) Independent Behavioral Health Assessment form is designed to collect comprehensive information on an individual's behavioral health status. The framework includes demographic details, behavioral health history, substance use history, physical health, legal status, family history, trauma history, living situation, educational and employment status, social and community integration, mental status examination, risk assessment, and cultural and language preferences. The goal is to accurately assess the individual's needs to provide tailored services and support for recovery and well-being.
Who should complete the 1915(c) Assessment form?
This assessment form should be filled out by a licensed mental health professional (LMHP) who is conducting an evaluation of the client or member in question. The LMHP uses the form to record observations, client or caregiver statements, and professional judgments about the client's mental, emotional, and physical health. This detailed evaluation helps in creating a comprehensive care plan that addresses the individual's various needs.
Is the 1915(c) Assessment form only for children and youth?
While the form is structured to be applicable for individuals across a range of ages, including children and youth, it specifically asks for information pertinent to the younger population, such as current educational placement and involvement with parents or primary caretakers. However, the comprehensive nature of the assessment makes it a valuable tool for adults as well, particularly in understanding the full scope of an individual’s behavioral health and social context.
What happens after the assessment form is completed?
Once the assessment is completed, the licensed mental health professional reviews the findings to determine the most appropriate services and supports for the individual. Recommended treatments, care levels, and the duration of services are identified based on the comprehensive evaluation documented in the form. These recommendations are then typically discussed with the client, their family or guardians, and possibly other members of the healthcare team to initiate a care plan. This collaborative approach ensures that the plan aligns with the individual’s specific needs and recovery goals.
How is confidentiality maintained with the 1915(c) Assessment form?
Confidentiality is of utmost importance when dealing with personal health information. Mental health professionals are expected to adhere to strict privacy and confidentiality laws and guidelines, such as those outlined in HIPAA (Health Insurance Portability and Accountability Act). Information gathered in the 1915(c) Assessment form is used solely for the purpose of providing care and support to the individual; it is protected and shared only with those directly involved in the individual's treatment and care, and only with the appropriate consents in place.
Can the information in the 1915(c) Assessment form be updated or changed?
Yes, the information in the 1915(c) Assessment form can be updated or changed as necessary. Behavioral, emotional, and physical health can evolve over time, requiring modifications to the care plan. Follow-up assessments are often conducted to capture any significant changes in the individual's condition, needs, or circumstances, ensuring that the provided services continue to be relevant and effective. These updates are critical to adapt to the individual’s progress or any new challenges they face on their recovery journey.
Filling out the 1915(c) Assessment form, designed for evaluating behavioral health needs, can be quite intricate. It demands careful attention to detail and an understanding of behavioral health history, medical conditions, and social situations. Nevertheless, errors are common, and recognizing these mistakes can prevent delays and inaccuracies in getting the necessary services.
A common mistake is incomplete demographic information. This section, which captures basic but crucial details like name, date of birth (DOB), and social security number (SSN), is often filled inaccurately or left blank. Such omissions can lead to processing delays or incorrect assessment outcomes.
Another error involves the behavioral health history section, particularly when respondents provide vague descriptions of the chief complaint. For an accurate evaluation, it’s essential to detail the symptoms, difficulties, or issues in the client's own words or as quoted by caretakers, leaving out no significant aspect.
People also frequently overlook the importance of detailing the presenting problem or relevant history comprehensively. Missing information about precipitating factors, onset/course of the issues, or expectations can result in an incomplete understanding of the client's needs, affecting the accuracy of the assessment.
Understating or omitting past psychiatric, placement history, and substance use history is another frequent oversight. It’s crucial to include all relevant information about previous diagnoses, treatments, hospitalizations, and substance use to ensure a complete behavioral health evaluation.
In the physical section, sometimes current medical conditions and medications are not fully reported. This lapse can lead to overlooking potential interactions between psychological treatments and current medications or medical conditions.
Another error occurs in the section about allergies. Failing to mention known drug or food allergies can pose serious risks if new medications are prescribed based on the assessment.
The sections requiring details about social, educational, and employment status often suffer from insufficient detail. Understanding the social supports, educational background, and employment situation is vital in formulating a comprehensive care plan that addresses all aspects of a client’s life.
Risk assessment areas are sometimes filled out without the necessary depth of detail. Assessing the risk of harm to self or others is a sensitive but crucial part of the assessment that requires thoroughness. Generalizing or overlooking information here can lead to inadequate safety planning.
Lastly, cultural and language preferences are often undervalued. Not specifying a client’s language, cultural beliefs, or values may result in a care plan that is not fully accessible or acceptable to them, impairing their recovery journey.
Understanding these common pitfalls and emphasizing the need for complete, detailed responses can significantly improve the quality and effectiveness of the 1915(c) Assessment process. By recognizing and avoiding these mistakes, individuals and caretakers can help ensure that the assessment accurately reflects the client's needs, leading to better-tailored and more effective care services.
The 1915(c) Independent Behavioral Health Assessment form is a comprehensive document used to gather detailed information about an individual's behavioral health. Alongside this form, several other forms and documents are frequently utilized to ensure a holistic approach to assessment and planning for an individual's care. These documents often accompany the 1915(c) form to provide a fuller picture of the individual's situation and needs.
Together, these forms create a comprehensive set of documents that support the proper assessment, planning, and management of care for individuals with behavioral health needs. They ensure that care is coordinated, holistic, and tailored to the unique circumstances of each individual.
The Personal Health Record (PHR) is a document that resembles the 1915(c) Assessment form in several ways. Both documents extensively collect health-related information, but the PHR focuses more broadly on a person’s overall medical history, medications, surgeries, allergies, and vaccinations. Like the 1915(c) form, a PHR provides a comprehensive overview of a patient’s health status at a glance. However, whereas the 1915(c) form is tailored specifically toward behavioral health assessments, a PHR encompasses all aspects of an individual’s health and medical history, making it a useful tool for managing one’s healthcare across different providers and care settings.
Another document similar to the 1915(c) Assessment form is the Comprehensive Psychosocial Assessment. This assessment shares a focus on behavioral health, looking into the psychological, social, and emotional aspects of an individual's life. It explores areas such as family history, personal relationships, substance use, employment, and mental health history in detail, akin to the 1915(c) form. Both forms are pivotal in creating a tailored care plan by gathering in-depth information about the individual’s life and mental health status. However, the Comprehensive Psychosocial Assessment might delve deeper into the psychosocial components, emphasizing the individual’s interaction with their environment and social networks.
The Substance Use Disorder Assessment forms bear a resemblance to the substance use sections of the 1915(c) form, particularly in their detailed inquiry into an individual’s history and patterns of substance use, types of substances used, and the impact on the individual’s life. These assessments are crucial for creating an effective treatment plan for substance use disorders, focusing on the specifics of usage, treatment history, and related behaviors. Both documents seek to identify the level of substance misuse and guide the subsequent steps in treatment or intervention, but a Substance Use Disorder Assessment specifically tailors its content to address the complexities of addiction and recovery.
Functional Behavioral Assessments (FBA) share similarities with the 1915(c) Assessment form, especially in the context of behavioral observations and identifying specific behaviors that require intervention. Both tools are employed to gain insights into challenging behaviors, particularly in children and adolescents, to devise strategies for behavioral modification. The FBA focuses on understanding the reasons behind certain behaviors and how environmental factors influence them, which complements the 1915(c) form’s objective of collecting comprehensive behavioral health information. While the FBA specifically targets behavioral issues and their triggers, the 1915(c) form provides a broader overview of the individual’s behavioral health needs.
When filling out the 1915(c) Independent Behavioral Health Assessment form, it's important to approach the task with thoroughness and accuracy. Here are some guidelines to follow:
Do:
Don't:
Understanding the 1915(c) assessment form can often be surrounded by misconceptions, which might affect its utilization and the benefits it extends to individuals in need. This document is integral to behavioral health assessments, providing a structured way to capture crucial information about an individual's mental health status, leading to appropriate care provision. Here are five common misconceptions about the 1915(c) assessment form:
Clarifying these misconceptions is crucial for healthcare providers, clients, and families alike, ensuring that the 1915(c) assessment form is used effectively to support individuals' behavioral health needs comprehensively.
Completing the 1915(c) Assessment form requires attention to detail and an understanding of the individual's needs and history. Here are key takeaways for effectively filling out and using this form:
Each part of the 1915(c) Assessment form plays a vital role in creating a comprehensive view of the individual's needs, helping professionals tailor interventions that promote recovery and well-being. Accurate and thoughtful completion of the form is therefore essential.
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