CWS REHABILITATION INITIAL ASSESSMENT State Form 54573 (1-11) FAMILY & SOCIAL SERVICES ADMINISTRATION RICHMOND STATE HOSPITAL GENERAL Client Name: (need full name at time of admission) Admission Date Avatar Chart Number: (month, day, year):  AM  PM Date of Assessment Time of Assessment: (month, day, year): Assessment Type:     Initial Initial Reassessment Annual Annual Reassessment Assessing Clinician: Assessing Clinician 2: Supervising Clinician: Notification Comments:    Draft / Pending Approval / Final: Draft Pending Approval Final Primary Language: (Aliased in from PM side) Preferred Language: Arabic  Chinese English    French German Italian    Japanese  Other  Russian Sign Language   Spanish Unknown  Interpreter Used:  No  Yes Language Comments: Informant Type:  Another provider Client  Current Assessments / Evaluations   Family / Significant other  Gatekeeper Justice system  Legal Representative   Records from previous admission  Other (specify) Informant Comments: (Identify specific re: source of information / informants - assessed - reliability, validity. Informant comments re: reason for admission or events leading up to admission, symptoms described / reported, etc.).
CWS REHABILITATION INITIAL ASSESSMENT State Form 54573 (1-11) FAMILY & SOCIAL SERVICES ADMINISTRATION RICHMOND STATE HOSPITAL GENERAL Client Name: (need full name at time of admission) Admission Date (month, day, year): Avatar Chart Number: Date of Assessment (month, day, year): Time of Assessment:  AM  PM Assessment Type:  Initial  Initial Reassessment  Annual  Annual Reassessment Assessing Clinician: Assessing Clinician 2: Supervising Clinician: Notification Comments: Draft / Pending Approval / Final:  Draft  Pending Approval  Final Primary Language: (Aliased in from PM side) Preferred Language:  Arabic  French  Japanese  Sign Language  Chinese  German  Other  Spanish  English  Italian  Russian  Unknown Interpreter Used:  No  Yes Language Comments: Informant Type:  Another provider  Family / Significant other  Legal Representative  Client  Gatekeeper  Records from previous admission  Current Assessments / Evaluations  Justice system  Other (specify) Informant Comments: (Identify specific re: source of information / informants - assessed - reliability, validity. Informant comments re: reason for admission or events leading up to admission, symptoms described / reported, etc.).
54573%20(1-11)%20cws%20rehabilitation%20initial%20assessment.docx