Fillable Printable Mental Health Evaluation Form - Minnesota

Mental Health Evaluation Form - Minnesota

Mental Health Clinic

Intake Assessment

Welcome to the Mental Health Clinic at Boynton Health Service. Before your first appointment, we’d like to

know some things about you and your concerns. This will assist us in helping you find what you are looking for.

What kind of services are you seeking?

____Individual cou nseling ____Medication evaluation/treatment ____Couple s counseling ___ _ Medical social work

____Group counseling ____Brief problem solving ____Required letter/documentation ____Alcohol/Drug assessment

Please describe the primary issue for your visit. You may use the descriptions on the back of this form to

assist you with your description. ___________________________________________________________

_____________________________________________________________________________________

There are some services that we are presently unable to offer or offer on a limited basis.

• ADD\ADHD: In order to be considered for ADD or ADHD medication treatment, you must provide us with copy

of your comprehensive ADD or ADHD evaluation for review prior to scheduling your first medication

appointment in the Mental Health Clinic. The Medical Social Worker can provide you with resources if you

require a n evaluation-- 612-624-8182.

• Eating Disorders: We provide an Eating Disorder Therapy program in coordination with medical and nutrition

services. We do not offer intensive Eating Disorder Treatment (including treatment for anorexia). Contact the

Medical Social Worker for resources– 612-624-8182.

• Long Term Therapy: The Mental Health Clinic utilizes a short-term model of psychotherapy. This means that

we are able to offer eleven individual or couples therapy visits within the period of one year. The Medical Social

Worker can p rovide you with resources– 612-624-8182.

• Legal Assessments: We are unable to provide legal assessments, with the exception of chemical health

assessm ents. The Medical Social Worker can provide you with re sources– 612-624-8182.

Psychiatric Hospitalizations/Past Treatment:

Mental Health Professiona l/Clinic: Situation/condition treated: Dates seen:

______________________________________ ________________________________ _________ _____

What medications, if any, are you currently taking or considering resuming?

__________________________________________________________________________________

The mental health professional that you will see at your first appointment will review the information that

you have provided. It is possible that they will want to talk to you by phone before you come in for the first

appointment. At what phone number may we reach leave a confidential message?

(____) ____ - ________

Age_____ Date of Birth_____________ Sex____ Email Address________________________

Mo/Day/Year

Freshman____Sophomore____Junior____Senior____Graduate____Professional____

Major area of study:________________________ Referred by_________________________________

If you are feeling acutely suicidal you must notify the Mental Health Clinic front desk so

they can arrange for you to speak with an Urgent Counselor.

Signature_______________________________ Date___________________

A reproduction of this form is as valid as the original

Label

Name:___________________________

MRN #:__________________________

Student ID #:______________________

Thefollowingaresometermsandshortdescriptionsofkeyareasofconcernsforwhichstudentsoftenseekhelpatourclinic.Ifany

oftheseareasofconcernarecausingsignificantdistressforyouatthistime,pleaseconsiderlistingthemonthefrontpageofthis

form.

Relationshipissues

mayrefertodifficultiesincommunication,respect,expectations,demands,fidelity,break‐uporotheraspectsof

romantic,family,work,friendship,roommateorschoolassociationswithothers.

Situationalanxiety

isanxietythatappearstobedirectlyrelatedtoanidentifiablesituation.

Generalanxiety

isanxietyassociatedwithworryaboutseveraldifferentareasofconcern.Thetermisusuallyusedtorefertoworry

andanxietythatispresentmoredaysthannotforatleast six‐monthsinduration.However,itiscommonforgeneralanxietytohave

beenpresentforyears.

Depression

referstopersistentorrecurrentsadnessorinabilitytoenjoythings.Itisoftenaccompaniedbyoneofmore

disturbancesinsleep,energy,concentration,andappetite.Ifyoubelievethatyourdepressionisdirectlyrelatedtoanevent,difficult

relationship,orenvironmentalcircumstancesyoumaywanttodescribethisas

asituationaldepression.

Moodswings

isageneraltermthatisusedcolloquiallytorefertoabroadrangeofmoodstatesthatincludebeingveryemotionally

reactivetolittleevents,moodsfrequentlyvaryingfromdepressiontofeelingnormal,ormoresignificantchangesofmoodbetween

prolongedstatesofdepressiontoasenseofhigh

energyassociatedfeelingsofelationorirritability(whichmayindicatehypomania

ormania).Ifyouhavemoodswingssomeindicationofhowtheseareexperiencedishelpful(e.g.irritableinresponsetominor

upsets)

Panic/anxietyattacks

arecharacterizedbytherapidonsetofanxietywithinafewminutesoftenoccurringwithlittleorno

provocation.Panicattacksareassociatedwithadditionalphysicalandemotionalsymptomswhichmayincluderapidorpounding

heart,shortnessofbreath,dizziness,trembling,asenseofdetachmentfromyoursurroundingorbody,

andafearofdyingorgoing

crazy.Gradualbuildupofanxietytoa“panicky”stateusuallydoesn’tindicateapanicattack.

Obsessions

areintrusivethoughtsorimagerythatarerecurrentanduncomfortable.Althoughobsessionscanbeaboutmany

differentissues,themostcommonareexcessiveconcernaboutgerms,dirtand/orcontamination,uncertaintyleadingtochecking,

healthconcerns,violentorsexualimagery,andunusualrulesthatmayneedtobefollowedtoavoid

feelinguncomfortableorto

avoidaperceivednegativeconsequence.Obsessionsareusuallyassociatedwithcompulsions.

Compulsions

aremotorormentalactsthatarefrequentlyrepeatedandcausedistressortakeupanexcessiveamountoftime(e.g.

anhourormoreperday).Thesemayincludecleaning,handwashing,arranging,followingself‐imposedrules,checking,and

countingamongotherbehaviors.

Bulimia

referstoaconditionassociatedwithcertainbehaviorsandthoughtscenteredaroundeatingincludingaconcernaboutbody

imageorgainingweightandattemptstocontrolweightbyforcingoneselftothrow‐up,exercisingexcessively,orusinglaxativesor

waterpills.

Anorexia

referstoaconditioninwhichapersonisoverlyconcernedaboutweight,hasdifficultyaccuratelyperceivingtheimageof

theirbody,andtriestolimitorloseweightbyrestrictingcalorieswhichresultsinasignificantweightlossbelowwhatwouldbe

expectedfortheirheight.

SocialAnxiety

isanxietyinspecificsocialsituations(suchasspeaking)orinsocialencountersingeneral.Anxietyisaccompaniedby

recurrentworrythatonewillembarrassoneselfbyone’sspeechoractionsorworrythatothersarealwaysscrutinizingone’sspeech

andbehaviors.

Academicdifficulties

canrefertoabroadrangeofproblemsincludingdifficultystudying,procrastination,testanxiety,andacademic

probationandmayrepresentthecauseoreffectofmentalhealthproblemssuchasdepressionandanxiety.Foracademic

difficultiesthatarenotaccompaniedbysignificantemotionalissues,studentsmightwanttofirstconsider

seekingassistanceat

UniversityCounselingandConsultingServiceswherespecializedacademicandcareercounselingisavailable.

Attentionalproblems

refertoproblemssustainingfocusandconcentration.Themostcommonreasonsforproblemswithattention

inUniversitystudentsaredepressionandanxiety,ortheconsequencesofexcessiveuseofmarijuanaoralcohol.Asmaller

percentageofstudentsexperiencethesedifficultiesduetoAttentionDeficitDisorder(ADD).

Post‐traumasymptoms

areassociatedwithexposuretoathreateningsituationoutsidetherangeofnormalexperiencesuchas

childhoodphysicalorsexualabuse,sexualassault,alifethreateningaccident,naturaldisaster,orcombat.Theycaninclude

emotionalnumbing,difficultyrecallingthetraumaticevent,excessiverecalloftheeventindreamsordaytime

recollections,always

beingonguard,andavoidanceorcuesthatremindoneofthetrauma.



Name: _________________________

Student ID #:

_______________________

Authorization for Release of Verbal Information

Client informat ion is confidenti al. This means that information that y ou provide to this clinic will not be rel eased to

any source outside of Boynt on Health S ervice witho ut your written permission.

Exceptions to this po licy include:

1. The reporti ng to county authorities of suspec ted abuse or neglect of children or vulnerabl e adults.

2. The informing of appropriate others if there is a clear and imminent danger of possible harm to you or

another pers on.

3. The releasing of records pursua nt to a valid court order signed by a judge.

In some cases patients may prefer that other individ ua ls be involved wit h the ir treatment plan or may an t icipate

that other interested parties may call in the future in attempts to assist with their care. If this is true for any of the

persons listed belo w, you may want to consider granting advance permissi on for us to speak with these parties.

Please provide us with the names and pho ne numbers of such individ uals an d sign your name granting us

permission. Granting this permission for release of verbal i nformation is voluntary. The rel ease of written records

requires separate written permission.

This release will take effect on the date signed and will b e i n effect for one year. Permission may be c anceled

with written not ification. Canceling permission will not have any effect on information released prior to the

notification of cancellation.

****************************************************************************************************

I authorize Boynton Health Service Mental Health Clinic to discuss my clinical care with the

following individuals for the purpose of assisting me in dealing with my condition.

Spouse/Significant Other

Name(s)________________________________________ Phone __________________

Parent (s)

Name (s)________________________________________ Phone __________________

University Department (s)

 Disability Services  University Counseling and Consulting

Other (s)

e.g. Academic Advisor, Athletic Trainer, Doctor, Therapist

Name ____________________________Relationship to Patient_________ Phone_______________

Patient Signature _____________________________________ Date _________________

A reproduction of this form is as valid as the original

08/20/2013

BOYNTON HEALTH SERVICE Print Name: ____________________

MENTAL HEALTH CLINIC

FAIL/LATE CANCEL POLICY Student ID #: ___________________

I, _____________________________ understand that missed or late-cancelled app o intments inter fere wi th

my tr ea tment and that of other s t udents who might have bee n seen at tha t time. I agr ee to the followi ng:

I w ill attend a l l sc he duled appointments a nd group sessions.

If I arrive 10 or more minut es late I may be asked to reschedule and be charged the late cancel fee.

If I ca nnot attend a scheduled appointment or gro up se ssion, I will canc el the appo intment by 5 PM of

the business day prior t o the appointment.

There is a $10 late-cancel fee for any appointment or group session that I do not

cancel by 5PM of the business day before the appointment.

There is a $20 no-show fee for any missed appointment or group session.

I understand that email reminders are a courtesy pro vided by Bo ynton Health Service. If I do not receive an

e mail reminder, I am sti ll responsible for keeping my appointment and late c ance l/fail fees a pp ly.

Fees are due whe n bil le d. Fees that are not paid may be transferred to student accounts receivable and

may interrupt my care. Student accounts receivable may asse ss additional fees to collect this balance.

I acknowledge that failing or late-cancelling two consecutive appointments or t hr ee a ppointments

w i thin six mont hs at the Menta l Hea lt h C linic w il l r esult in a scheduling ho ld being place d on my

account. This means I will not be able to schedule appointments with the Mental Health Clinic. This hol d

can only be remo ved by pre s enting in person at the Boynt on Healt h Service Pa t ient Acc ount ing Office

(N3 25). All outstanding late cancel or fail fees must be paid at that time. Once the hold is re moved, I mu s t

present in person at the Mental Health Clinic to schedule my ne xt appointment.

If I do not take steps to remov e the hold, Boynton Mental Health Clinic may terminate care with me.

T ermination of care will e nd the responsibility of the Mental Health Clinic to see me as a patient. I

understand it will then be my resp onsibilit y to find another mental health provider to continue my care and

that the Me ntal He a lth Cli nic will work with me to facilitate this transfer of care. In such circ umstances the

Mental Hea lth C linic will be willin g to provide urgent cons ultation for up to 30 days a fter I have received

notifica tion of my inelig ibility to be seen at the Menta l Healt h Clinic.

I recognize that Bo ynton Health Service will be under no obligation to pay for any mental health care

following terminatio n from the Mental Health Clinic. It will be my sole r e sp on sib ility to c over these

expe ns es.

Signature___________________________________ Date________________

A reproduction of this form is as valid as the original.