Client Agency Assessment

Client Name:

Client Agency Assessment

Initial Screening:

Presenting Problem and Duration of Problem:

Are there any events or circumstances that may have impacted or have contributed to this presenting problem?

Prior Mental Health Treatment?

Yes ___ No___

Past or Current Significant Medical Issues?

Yes ___ No___

DCFS Mandated?

Yes ___ No___

Court Ordered for Treatment?

Yes ___ No___

For any Yes responses to the question above, please provide further information.

Describe the client’s current housing situation.

1

Self-Harm and Aggressive Behaviors

Are there current thoughts of self-harm/suicide?

Yes ___ No___

Have there been past thoughts of self-harm/suicide?

Yes ___ No___

Has client had prior suicide attempts?

Yes ___ No___

Does client have current thoughts of harming another person?

Yes ___ No___

Has there been a history of injuring another person?

Yes ___ No___

Have there been current or past incidents of injuring animals?

Yes ___ No___

Has client been accused of being a perpetrator of violence/abuse?

Yes ___ No___

For any Yes responses to the question above, please provide further information.

Trauma and Abuse

2

Has there been recent trauma and or abuse exposure?

Yes ___ No___

Has there been a recent death in the family?

Yes ___ No___

Has client been a past victim of violence/abuse/neglect?

Yes ___ No___

Additional comments/information:

Daily Functioning

Is client able to care for personal hygiene and grooming?

Yes ___ No___

Is client able to maintain appropriate work/school/household routines?

Yes ___ No___

Are client’s current sleeping and eating routines satisfactory?

Yes ___ No___

For any No responses above please provide further information.

Drug & Alcohol Use

3

Does client use drugs or alcohol?

Yes ___ No___

Types of drugs used (highlight)

Alcohol Cocaine Heroin Inhalant Marijuana Meth

Polysubstance Use Prescription Medication Other

If other, please specify:

Briefly describe past or current substance use/abuse:

Additional comments/Information:

Psychosocial Information

Relevant family history, current living situation, social support, financial situation:

4

Client’s strengths/areas for growth, additional risk factors:

5