Child Hearsay Evaluation Statement

HOPE HAVEN PSYCHOLOGICAL RESOURCE, LLC

5610 Crawfordsville Road, Suite 701 Indianapolis, Indiana 46224-3739 Phone: 317.241.4673, Fax: 317.241.0201 www.hopehavenpsych.org Clinical Interview and Mental Status

Name: Date of Birth:

Age: Dates of Intake Sessions:

Clients Presenting Concern

What is your highest year of school completed. Note important hx for academics (Last School Attended, Grades, Suspension, Expulsions, Special Needs, Attitude Towards School, etc.)

Marital Status of Parents Never Married Divorced Separated

Where did you grow up?

Describe your household a child (who was there, what was it like, financial concerns, main caregivers, relocations, deaths)

Describe your PAST relationship with your MOTHER

Describe your CURRENT relationship with your MOTHER

Describe your PAST relationship with your FATHER

Describe your CURRENT relationship with your FATHER

What do you remember about your parents’ relationship? (Including Step, Adoptive, Adult Intimate Relationships)

Does anyone in your family serve as a current support (details)?

Siblings Name Sex Age Legal/Substance/Mental Siblings/Half/Adopted/ Health Concerns Step and Description of Relationship

Children’s Names Age Sex Legal/Substance/Mental Brief Description of Relationship Health Concerns with Child

Describe your average day

Are you currently in a relationship Yes No If yes, please describe

What are some activities that you engage in when you are not at work or active with your children

Have you ever been engaged Yes No Number of times

What is your marital status? Single Divorced Separated Partnered Widowed Number of Marriages

Age @ Length of Children from Relationship Specifics Marriage Marriage Marriage

Legal History Number of Arrest, Charges/Offenses, Number of times incarcerated (length)

Are you currently on Probation/Parole

Employment History Are you currently work Yes No Current Employ (Specifics: Place of Employment, Duties, Employment Time Span, Work Attitude, Concerns, Stressors)

Last three places of employment (Employment Specifics, Reason for Ending, Thoughts about ending)

Have you had problems maintaining/obtaining employment

Have you ever been in the military YES NO (Describe Below)

Substance Abuse (TOPIC CONSIDERATIONS) Amount of … used in a day Do you reach for a … in the morning Have you ever tried to quit… How long have you had this usage How long can you go during your day When and how long did this last What led to a change in your usage without … What led to you … again When did you begin… Do you or have you ever used drugs or alcohol? YES NO Substance Onset Freq. of Use Using companion Age Alcohol

Hallucinogens (PCP, Angel Dust, Substance Usage Description Mushrooms, Bath Salt) Amphetamines (Meth, Speed, Ritalin, Adderall, Dexedrine) Marijuana Hash Inhalants Benzodiazepines (Xanax, Valium, Diazepam) Do you have family members/friends/significant others who struggle(d) with substance abuse (specifics, impact on client)?

What is your longest length of sobriety (obtain specifics, dates, substance, Factors Affecting Relapse?)

How have drugs and/or alcohol impacted your life, Would you consider yourself to have a substance abuse concern

Prior substance Abuse Tx: When, What did it involve..

NICOTINE USAGE Do you notice any change in your body as a result of Substance, Alcohol, or Nicotine Usage (etc.) Coughing Feeling Winded Change in appetite Other Headaches Irritation

Medical History Height: Weight:

Have you ever had any miscarriages/Abortions

Do you have any major illnesses or diseases?

Have you had any major surgeries (Dates, Hospitalization, etc.)

Do your family members have any major medical problems?

Average amount of sleep each night

Description of Sleep (Falling to sleep, Waking, Nightmares, Feeling Rested, Disruptions, etc)

Description of Appetite (changes, weight fluctuations, body image attitude etc.)

Stress Levels 0 (none)--- 5 (some) ---10 (a lot) Physical Signs of Stress Hair Loss Change in Menstrual Digestion Challenges Twitching or Numbness Skin Rashes/Acne Cycle Fatigue Excessive Worry Physical Tension Headaches Difficulty Concentrating Other (please explain)

Believed Source of Stress (Methods of Stress Relief, Past and Present)

Have you ever been hospitalized or in a treatment facility for mental health concerns? Age, How long, Where, Rationale?

Have you ever seen a counselor, psychologist, etc? Age, How long, Where, Rationale?

Have you ever attempted/thought about suicide? Age, How long, Where, Rationale?

Have you ever had any AH/VH/Delusions (thought someone was out to get you-like CIA)?

Personal Mental health concerns (history, changes in mood, fears, behaviors, unusual thoughts, etc)?

Does anyone in your family seem to be struggle (or has been diagnosed) with mental health?(nerves, dep, mood swings)

Mental Status Orientation (Within Normal Limits) Responses Oriented to Person Oriented to Place Oriented to time Oriented to Situation Describe how you traveled here today

Dress Appropriate Casual Work Neat Clean Unkempt Disheveled Self Neglect Affect Appropriate Full Euthymic Tearful Withdrawn Blunted Constricted Manic Labile Mood Appropriate Happy Sad Angry Scared Anxious Frustrated Neutral Incongruent Thought Appropriate Alert Logical Confused Ruminative Loose Association Grandiose Obsessive

Speech Appropriate Rapid Slow Tangential Slurred Incoherent Tangential Goal Directed Loud Vague Restricted Behavior Cooperative Friendly Pleasant Open Oppositional Resistant Submissive Frightened Defensive Evasive Seductive Irritable Hostile Agitated Angry Pessimistic Optimistic Indifferent Alert Shy

Ideation Appropriate/NONE Suicidal Homicidal Intent Threat CONTRACT? N/A YES NO Perceptions Appropriate AH VH TH SH Delusion Paranoid Hypersensitive Depersonalization Distorted Attention Good Fair Poor Memory G F P Insight G F P Judgment G F P Motivation G F P Intellect Abv Avg Avg Blw Avg Impaired Eye Contact Appropriate Avoided Intense/Starring None Strengths

Areas of Growth

Summary, etc.

Diagnostic Impression/Considerations Axis I Axis II Axis III Axis IV Axis V Current GAF at time of evaluation: