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Psychiatric Assessment

By Ray Watkins,2014-06-28 13:45
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Psychiatric Assessment ...

Iowa Attachment D-3 (c)

    ASSESSMENT TOOL

     Additional Notes Assessment

     A. Assessment

    1. Child presents with a mental disorder as supported by the DSM- __________

    IV diagnostic criteria. He/she does not present with a mental

    retardation diagnosis. A substance abuse diagnosis alone is

    not sufficient for involvement in the Children’s Mental Health

    Waiver.

    2. Level of Stability

    a) The child demonstrates a risk to self and/or others but can be

     __________ managed with services available through the Children’s Mental

    Health Waiver.

    Displays concerns requiring verbal intervention

    ______

    Displays concerns requiring physical intervention

    ______

    Displays concerns requiring behavior management

    ______ Waiver Assessment Tool

    Iowa Attachment D-3 (c)

Displays concerns requiring a structured environment

    ______

Displays concerns requiring medication management, if

    clinically indicated.

    ______

    *Check areas that require verbal or physical

    intervention and specify in additional notes.

    1. Self-injurious behavior

    ?

    2. Verbal aggression

    ?

    3. Physical aggression

    ?

    4. Destruction

    ?

    5. Stereotypical, repetitive behavior

    ?

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    6. Antisocial behavior

    ?

    7. Depressive symptoms

    ?

    8. Elopement

    ?

    9. Risky or inappropriate sexual behavior

    ?

    10. Eating disorders

    ?

    11. Abuse of chemicals or alcohol

    ?

    12. Other; Specify in additional notes

    ?

    b) The child demonstrates the ability to engage in activities of

    daily living but lacks adequate medical/behavioral stability

     __________ and/or social and familial support to maintain or develop age-

    appropriate cognitive, social and emotional processes.

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

There is evidence that the family/caregiver(s) understand, are

    able to, willing to and committed to providing the level of care,

    ______ treatment, cooperation and supervision required for the child.

Family/caregiver(s) display difficulty in providing the level of

    care, treatment and/or supervision in supporting the child.

    ______

    *Check each area that applies and specify in

    additional notes.

    1. Physical abuse

    ?

    2. Sexual abuse

    ?

    3. Neglect in meeting the child’s needs

    ?

    4. Parental/caregiver substance use issues

    ?

    5. Parental/caregiver mental health issues

    ?

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    6. Parental/caregiver medical issues

    ?

    7. Parental/caregiver criminal issues

    ?

    8. Domestic violence

    ?

    9. Siblings with special needs

    ?

    10. Housing issues

    ?

    11. Financial issues

    ?

    12. Other; specify in additional notes

    ?

c) The child is medically stable but may require occasional

    medical observation and care.

     __________

    Waiver Assessment Tool

Iowa Attachment D-3 (c)

No medical problems are present ______

Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    Medical problems are present but child is able to manage ______ them independently

    Medical problems are present and child requires assistance ______ to manage his/her care

    *Check areas that require direct personal assistance

    and specify in additional notes.

    ? 1. Ambulation

    ? 2. Musculoskeletal, fine or gross motor skills

    ? 3. Toileting habits

    ? 4. Incontinence (bladder and/or bowel)

    5. Medications

    ? a. Oral medications, takes with assistance

    ? b. Requires physician monitoring and frequent

    lab values

    ? 6. Sensory perceptions including vision and/or hearing

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    ? 7. Speech

    ? 8. Other; specify in additional notes

    3. Degree of Impairment

a) The child has impairment in judgment, impulse control and/or

    cognitive/perceptual abilities arising from a mental disorder that

     __________ indicate the need for close monitoring, supervision and

    intensive intervention to stabilize or reverse the dysfunction.

    Alert and oriented with significant alteration in self-concept or

    mood

    ______

    Cognitive impairment (e.g. orientation, attention,

    concentration, perception, memory, reasoning, and/or self

    ______ direction)

    Exhibits mental status changes consistent with a psychiatric

    disorder

    ______

    The child demonstrates impairment in the ability to take care

    of personal grooming/hygiene needs or to cooperate in

    ______ meeting those needs.

    *Check areas that require direct personal assistance

    and specify in additional notes.

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    1. Dressing and/or undressing

    ?

    2. Washing and/or bathing

    ?

    3. Oral hygiene

    ?

    4. Hair care

    ?

    5. Shaving

    ?

    6. Menses care

    ?

    7. Other; Specify in additional notes

    ? The child demonstrates impairment in the ability to

    independently complete domestic tasks without close

    ______ monitoring and supervision.

    Waiver Assessment Tool

    Iowa Attachment D-3 (c)

    *Check areas that require direct personal assistance

    and specify in additional notes.

    1. Home skills

    ?

    2. Food preparation

    ?

    3. Clothes and laundry care

    ?

    4. Other; specify in additional notes

    ? The child demonstrates impaired self-advocacy skills with a lack of appropriate boundaries and/or inability to

    independently seek help or resources when necessary

    ______

    *Check all that apply and specify in additional notes.

    ? 1. Places self in risky situations

    ? 2. Poor social boundaries

    Waiver Assessment Tool

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