<p> My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>Date of Service: </p><p>Caretaker(s) Relationship </p><p>Address: </p><p>Home Phone Work Phone______Other______</p><p>Youth & Family Services Worker_NA______Relationship______</p><p>Address ______</p><p>Office Phone ______Other Phone______Fax______</p><p>Present Living Situation</p><p>Name Relationship AGE/DOB ______</p><p>Available Resources for Client</p><p>Contact Name Phone Agency/Relationship 1. 2.______3.______4.______5.______</p><p>Page 1 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>Chief Complaint </p><p>History of Present Illness (symptom onset, duration, precipitating events)</p><p>Risk Assessment Potential danger to self? yes no suicidal ideation plan recent attempt self-mutilation cruelty to animals witness to domestic violence yes no Describe: </p><p>Past danger to self? yes no past suicidal ideation past attempt fire setting cruelty to animals?</p><p>Describe any history: </p><p>Potential danger to others? yes no assaultive ideation plan attempt Describe history: </p><p>Access to firearms? yes no details______</p><p>Behavior Patterns:</p><p>Eating/Appetite: no problems weight increase/decrease of ___ lbs. in __weeks/months loss of appetite increased appetite food cravings laxative abuse skipping meals bingeing vomiting diuretic use compulsive exercising</p><p>Sleeping pattern: no change increased decreased difficulty falling asleep frequent awakenings sleeping during day nightmares/terrors sleep medication Self care: no problems Difficulty with: bathing dressing getting out of bed motivation/interest chores social interaction enuresis encopresis Page 2 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>Energy: excessive energy lacks energy</p><p>Pain: Are you having pain now? yes no Are you being treated by your primary physician? yes no If no, therapist encouraged client to seek services of PCP? yes no</p><p>Significant Family History</p><p>Medical History Allergies: yes no type: </p><p>Reaction: yes no describe:______Operations and dates: Current medications: </p><p>Developmental Milestones</p><p>Do you have any concerns about your child’s growth? Any complications during pregnancy or delivery? Length of pregnancy? ___weeks birthweight_____ lbs. _____ oz. Age at which child: rolled over:_ ___ sat up:______crawled:______stood alone:_____ walked:______said single words:______2-word sentences______3-word sentences:______</p><p>Any concerns about motor skills (running, walking, writing, use of scissors)? Describe?______</p><p>Social History:</p><p>Recent family stressors/losses: History of abuse (current & past) none emotional physical sexual Describe:______</p><p>Page 3 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) Legal History: none training school/ detention probation past charges current charges</p><p>Mental Health Exam: Mood: appropriate euthymic depressed sad anxious irritable maniac euphoric blunted flat labile tearful Describe:______</p><p>Thought content: appropriate obsessions paranoia delusions preoccupation Describe:______</p><p>Thought process: slow normal circumstantial blocking tangential flight of ideas Hallucinations: none auditory visual olfactory tactile gustatory Orientation: Person: yes no Place: yes no Time: yes no Memory: Short term: intact impaired Long Term: intact impaired Judgment: good fair poor Insight: age appropriate limited poor Concentration: good fair poor Motor activity: appropriate for age agitated/hyperactive hypoactive</p><p>Substance Abuse History: Substance Quantity/Frequency Route of Administration Age at first use/How long ______</p><p>Past Psychiatric or Substance Abuse Treatment Facility/Provider Type Level input/output Year LOS Comments ______</p><p>Page 4 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>Family History Name Relationship Alcohol Drugs Physical/Sex Abuse Mental Illness</p><p>Ethnic/Cultural/Spiritual Influences None ______Ethnic______Cultural______Spiritual______Sexuality______</p><p>Education: Highest level completed____ Currently in school_yes____ School_ language:_English______Able to read: ______Able to write: ______Can patient understand and follow directions?______Special services: Are there any barriers to remember? yes no describe:______</p><p>Formulation (supporting documentation for diagnosis): ______</p><p>Strength/Weaknesses: ______</p><p>Page 5 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) ______</p><p>Diagnostic Impression:</p><p>______</p><p>Page 6 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>I agree that I participated in the assessment:</p><p>Client: ______Date: ______</p><p>Guardian: ______Date: ______</p><p>Clinician: ______Date: ______</p><p>Page 7 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) Revised 01/18/2015</p><p>Page 8 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>MBH Inc. Individual Counseling Client: Record Number: Date: Medicaid Number: DIAGNOSIS(ES): Type: Principal (P) Both Principal & Primary (B) Primary (R) Additional (A) Axis Code Type Description</p><p>Supports/Strengths</p><p>Date Date</p><p>Preferences</p><p>Date Date</p><p>Problem(s) / Need(s)</p><p>Date Date</p><p>Page 9 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)</p><p>MBH Inc. Service Plan Client: Record Number: Medicaid Number: Date: Service(s)/Intervention(s) Responsible Person/Position Goal (including frequency)</p><p>Outpatient Individual and/or Therapist Family Treatment 2 – 4 times a month</p><p>Target Reviewed Status Justification for Continuation/Discontinuation of Goal: Date Date Code</p><p>Status Codes: N=New R=Revised O=Ongoing A=Achieved D=Discontinued Date: Service(s)/Intervention(s) Responsible Person/Position Goal (including frequency)</p><p>Outpatient Individual and/or Therapist Family Treatment 2 – 4 times a month</p><p>Target Reviewed Status Justification for Continuation/Discontinuation of Goal: Date Date Code</p><p>Status Codes: N=New R=Revised O=Ongoing A=Achieved D=Discontinued</p><p>Page 10 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) SERVICE PLAN</p><p>Client: Record:</p><p>I had input in the treatment plan/I agree with this plan.</p><p>______Date: Staff Signature Date: Parent Signature</p><p>Page 11</p>