Follow the steps to successfully complete your Adult Full Assessment

1. Press the ‘Get Form’ button to access the Adult Full Assessment and open it in your preferred digital format.
2. Begin by providing the date of first assessment contact and the name and discipline of the assessing practitioner. Make sure to include any other individuals interviewed during the assessment.
3. In the Demographic Data & Special Service Needs section, fill in your date of birth, referral source, gender, ethnicity, marital status, and preferred language. If applicable, indicate whether any interpretive services were provided and note any cultural or physical challenges that may apply.
4. For the Reason for Referral/Chief Complaint section, describe any precipitating events, current symptoms, and behaviors along with their impact on life functioning. It is essential to include client strengths that could assist in achieving treatment goals.
5. In Mental Health History, chronicle any previous mental health problems and treatments. Note whether the client has had any psychiatric hospitalizations or outpatient treatment, and document past suicidal or homicidal thoughts or attempts.
6. List all current and past medications in the Medications section, including their dosage, frequency, and the client's perspective on effectiveness and side effects.
7. Address any substance use or abuse concerns, referring to the relevant questions in the Substance Use/Abuse section to document alcohol and drug use patterns.
8. Provide medical history details, such as any major medical problems and contact information for the client’s primary care physician.
9. In the Psychosocial History section, outline how mental health status impacts education, employment, legal status, living arrangements, social support systems, and family dynamics. Include any relevant strengths and vulnerabilities.
10. Complete the Mental Status Evaluation by checking all descriptions that accurately apply and providing comments where necessary.
11. Summarize your findings in the Summary and Diagnosis section. Ensure to include details about risk assessments, strengths and weaknesses, diagnostic codes, and recommendations for continued care.
12. Once the form is complete, review for accuracy. You can then save changes, download the completed assessment, print it, or share it as needed.

Start filling out your Adult Full Assessment online today to ensure accurate mental health support.