Avoidant/Guarded/ Silly Nervous/ Anxious Preoccupied Restless Demanding Suspicious Controlling Unable to perceive Provocative Hyperactive Impulsive Agitated pleasure Assaultive Aggressive Compulsive Relaxed WNL Mute Over-talkative Slowed Slurred Stammering Speech: Rapid Pressured Loud Soft Repetitive Emotional State- WNL Not feeling anything Irritated Happy Angry Hostile Mood (in Depressed, Anxious Afraid, person’s words): sad Apprehensive Emotional WNL Constricted Changeable Inappropriate Flat Affect Full Blunted, unvarying WNL Anxiety, fear, Sadness, depression Anger, hostility, apprehension irritability Facial Expression Elated Expressionless Inappropriate Unvarying WNL Perception: Hallucinations- Tactile Auditory Visual Olfactory ** Command Thought Content: WNL None Reported Grandiose Persecutory Somatic Illogical Chaotic Delusions- Religious Preoccupied Obsessional Guarded Phobic Suspicious Guilty Other Content- Thought Thought insertion Ideas of reference broadcasting Decreased thought Flight of WNL Incoherent Blocked flow ideas Thought Process: Loose Racing Chaotic Concrete Tangential Intellectual Lessened fund of Impaired Impaired calculation Functioning: WNL common concentration ability knowledge Intelligence Develop. No formal Borderline Average Above average Estimate - Disabled testing Orientation: WNL Disoriented to: Time Person Remote Short Attention Memory: WNL Impaired: Immediate recall Recent memory memory Span Difficulty acknowledging presence of Mostly blames other Insight: WNL Thinks he/she has no problems psychological problems for problems Impaired Ability to Make Judgment: WNL Mild Moderate Severe** Reasonable Decisions: Past Attempts to Self** Others** Harm Self or None Reported Others: Self None reported Cutting** Burning** Other: Thoughts: Suicidal None reported Passive SI** Intent** Plan** Means** Thoughts: Aggressive None reported Intent** Plan** Means** Thoughts: Comments: Person’s Name MI Last): Record #: Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors that help the client achieve his/her Comment on all areas Personal Qualities Adaptable, Persistent, – Curious, Playful, Creative, Confident, Optimistic, Resilient Living Situation, Family, and Interpersonal Relationships
Silly Avoidant/Guarded/ Suspicious Nervous/ Anxious Preoccupied Restless Demanding Controlling Unable to perceive pleasure Provocative Hyperactive Impulsive Agitated Assaultive Aggressive Compulsive Relaxed Speech: WNL Mute Over-talkative Slowed Slurred Stammering Rapid Pressured Loud Soft Repetitive Emotional (in person’s words): WNL Not feeling anything Irritated Happy Angry Hostile Depressed, sad Anxious Afraid, Apprehensive Emotional State- Affect WNL Constricted Changeable Inappropriate Flat Full Blunted, unvarying Facial Expression WNL Anxiety, fear, apprehension Sadness, depression Anger, hostility, irritability Elated Expressionless Inappropriate Unvarying Perception: WNL Hallucinations- Tactile Auditory Visual Olfactory Command ** Thought Content: WNL Delusions- None Reported Grandiose Persecutory Somatic Illogical Chaotic Religious Other Content- Preoccupied Obsessional Guarded Phobic Suspicious Guilty Thought broadcasting Thought insertion Ideas of reference Thought Process: WNL Incoherent Decreased thought flow Blocked Flight of ideas Loose Racing Chaotic Concrete Tangential Intellectual Functioning: WNL Lessened fund of common knowledge Impaired concentration Impaired calculation ability Intelligence Estimate - Develop. Disabled Borderline Average Above average No formal testing Orientation: WNL Disoriented to: Time Person Memory: WNL Impaired: Immediate recall Recent memory Remote memory Short Attention Span Insight: WNL Difficulty acknowledging presence of psychological problems Mostly blames other for problems Thinks he/she has no problems Judgment: WNL Impaired Ability to Make Reasonable Decisions: Mild Moderate Severe** Past Attempts to Harm Self or Others: None Reported Self** Others** Self Thoughts: None reported Cutting** Burning** Other: Suicidal Thoughts: None reported Passive SI** Intent** Plan** Means** Aggressive Thoughts: None reported Intent** Plan** Means** Comments: Person’s Name MI Last): Record #: Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors that help the client achieve his/her Comment on all areas Personal Qualities – Adaptable, Persistent, Curious, Playful, Creative, Confident, Optimistic, Resilient Living Situation, Family, and Interpersonal Relationships Mood
msdp_at_child_comprehensive_01_15_15lockedfeb2015.docx