contrib/forms/assessment_intake/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: assessment_intake");
   5 ?>
   6 <html><head>
   7 <? html_header_show();?>
   8 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <form method=post action="<?echo $rootdir;?>/forms/assessment_intake/save.php?mode=new" name="my_form">
  12 <br>
  13 <span class="title"><center>Assessment and Intake</center></span><br><br>
  14 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  15 <img src="../../../images/space.gif" width="5" height="1">
  16 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  17  onclick="top.restoreSession()">[Don't Save]</a></center>
  18 <br>
  19
  20 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  21 $result = SqlFetchArray($res); ?>
  22 <b>Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  23 <img src="../../../images/space.gif" width="572" height="1">
  24 <b>Date:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  25 <b>SSN:</b>&nbsp;<?php echo $result['ss'];?><img src="../../../images/space.gif" width="172" height="1">
  26 <label><b>DCN:</b>&nbsp;<input type="text" name="dcn"></label><img src="../../../images/space.gif" width="125" height="1">
  27 <label><b>Location:</b>&nbsp;<input type="text" name="location"></label><br><br>
  28 <b>Address:</b>&nbsp; <?php echo $result['street'] . ',&nbsp' . $result['city']  . ',&nbsp' . $result['state'] . '&nbsp;' . $result['postal_code'];?><br><br>
  29 <b>Telephone Number:</b>&nbsp; <?php echo $result['phone_home'];?><img src="../../../images/space.gif" width="400" height="1">
  30 <b>Date of Birth:</b>&nbsp;<?php echo $result['DOB'];?><br><br>
  31 <label><b>Time In:</b>&nbsp;<input type="text" name="time_in"></label><img src="../../../images/space.gif" width="65" height="1">
  32 <label><b>Time Out:</b>&nbsp;<input type="text" name="time_out"></label><img src="../../../images/space.gif" width="65" height="1">
  33 <label><b>Referral Source:</b>&nbsp;<input type="text" name="referral_source"></label><br><br>
  34 <b>Purpose:</b>&nbsp; <input type=checkbox name='new_client_eval'  ><b>New client evaluation</b><img src="../../../images/space.gif" width="10" height="1">
  35 <input type=checkbox name='readmission'  ><b>Readmission</b><img src="../../../images/space.gif" width="35" height="1">
  36 <input type=checkbox name='consultation' ><b>Consultation</b><br><br>
  37 <label><b>Copy sent to:</b>&nbsp;<input type="text" name="copy_sent_to"></label><br><br>
  38 <b>Why is Assessment being requested (Goals and treatment expectations of the individual requesting services):</b><br>
  39 <textarea cols=100 rows=3 wrap=virtual name="reason_why" ></textarea><br>
  40 <b>Behavior that led to Assessment:</b><br>
  41 <textarea cols=100 rows=5 wrap=virtual name="behavior_led_to" ></textarea><br><br>
  42 <b><u></u>Areas of Functioning:</b><br><br>
  43 <b>School/Work:</b><br>
  44 <textarea cols=100 rows=3 wrap=virtual name="school_work" ></textarea><br><br>
  45 <b>Personal Relationships (Intimate):</b>&nbsp;
  46 <textarea cols=100 rows=4 wrap=virtual name="personal_relationships" ></textarea><br><br>
  47 <b>Family Relationships:</b>&nbsp; &nbsp;
  48 <input type=checkbox name='fatherc'  >&nbsp;<b>Father involved/present/absent (Describe relationship)</b><br>
  49 <textarea cols=100 rows=3 wrap=virtual name="father_involved" ></textarea><br>
  50 <input type=checkbox name='motherc'  >&nbsp;<b>Mother involved/present/absent (Describe relationship)</b><br>
  51 <textarea cols=100 rows=3 wrap=virtual name="mother_involved" ></textarea><br><br>
  52 <b>Number of children:</b>&nbsp;<input type="text" name="number_children"><br><b>Names, ages, quality of relationship(s):</b><br>
  53 <textarea cols=100 rows=3 wrap=virtual name="siblings" ></textarea><br><br>
  54 <b>Other family relationships:</b><br>
  55 <textarea cols=100 rows=2 wrap=virtual name="other_relationships" ></textarea><br><br>
  56 <b>Social Relationships (Peers/Friends):</b><br>
  57 <textarea cols=100 rows=3 wrap=virtual name="social_relationships" ></textarea><br><br>
  58 <b>Psychological/Personal Functioning (Current symptons):</b><br>
  59 <textarea cols=100 rows=3 wrap=virtual name="current_symptoms" ></textarea><br><br>
  60 <b>Personal resources and strengths (including the availability & use of family and peers):</b><br>
  61 <textarea cols=100 rows=3 wrap=virtual name="personal_strengths" ></textarea><br><br>
  62 <b>Spiritual:</b>&nbsp;<input type="text" name="spiritual">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
  63 <b>Legal:</b>&nbsp;<input type="text" name="legal"><br><br>
  64 <b>Prior Mental Health History/Treatment:</b><br>
  65 <textarea cols=100 rows=3 wrap=virtual name="prior_history" ></textarea><br><br>
  66 <b>Number of admissions:</b>&nbsp;<input type="text" name="number_admitt">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
  67 <b>Types of admissions:</b>&nbsp;<input type="text" name="type_admitt"><br><br>
  68 <b>Alcohol and substance use for the past 30 days:</b><br>
  69 <textarea cols=100 rows=3 wrap=virtual name="substance_use" ></textarea><br><br>
  70 <b>Substance abuse history (Include duration, patterns, and consequences of use):</b><br>
  71 <textarea cols=100 rows=3 wrap=virtual name="substance_abuse" ></textarea><br><br>
  72 <b><u>Diagnoses</u></b><br><br>
  73 <b>Axis I:</b><br>
  74 <textarea cols=100 rows=3 wrap=virtual name="axis1" ></textarea><br><br>
  75 <b>Axis II:</b><br>
  76 <textarea cols=100 rows=3 wrap=virtual name="axis2" ></textarea><br><br>
  77 <b>Axis III:</b><br>
  78 <textarea cols=100 rows=3 wrap=virtual name="axis3" ></textarea><br><br>
  79 <b><u>Allergies/Adverse reactions to medications:</u></b>&nbsp;<input type="text" name="allergies"><br><br>
  80 <b>Axis IV Psychosocial and environmental problems in the last year:</b><br>
  81 <input type=checkbox name='ax4_prob_support_group'  >&nbsp;<b>Problems with primary support group</b>
  82 <img src="../../../images/space.gif" width="35" height="1">
  83 <input type=checkbox name='ax4_prob_soc_env'  >&nbsp;<b>Problems related to the social environment</b><br>
  84
  85 <input type=checkbox name='ax4_educational_prob'  >&nbsp;<b>Educational problems</b>
  86 <img src="../../../images/space.gif" width="5" height="1">
  87 <input type=checkbox name='ax4_occ_prob'  >&nbsp;<b>Occupational problems</b>
  88 <img src="../../../images/space.gif" width="5" height="1">
  89 <input type=checkbox name='ax4_housing'  >&nbsp;<b>Housing problems</b>
  90 <img src="../../../images/space.gif" width="5" height="1">
  91 <input type=checkbox name='ax4_economic'  >&nbsp;<b>Economic problems</b><br>
  92 <input type=checkbox name='ax4_access_hc'  >&nbsp;<b>Problems with access to health care services</b>
  93 <img src="../../../images/space.gif" width="5" height="1">
  94 <input type=checkbox name='ax4_legal'  >&nbsp;<b>Problems related to interaction with the legal system/crime</b><br>
  95 <input type=checkbox name='ax4_other_cb'  >&nbsp;<b>Other (specify):</b><br>
  96 <textarea cols=100 rows=2 wrap=virtual name="ax4_other" ></textarea><br><br>
  97 <b>Axis V Global Assessment of Functioning (GAF) Scale (100 down to 0):</b>
  98 <img src="../../../images/space.gif" width="5" height="1"><br>
  99 <b>Currently</b><input type="text" name="ax5_current">
 100 <img src="../../../images/space.gif" width="5" height="1">
 101 <b>Past Year</b><input type="text" name="ax5_past"><br><br>
 102 <b><u>Assessment of Currently Known Risk Factors:</u></b><br><br>
 103 <b>Suicide:</b><br><input type=checkbox name='risk_suicide_na'  >&nbsp;<b>Not Assessed</b>
 104         <img src="../../../images/space.gif" width="5" height="1">
 105         <b>Behaviors:</b>&nbsp;
 106         <img src="../../../images/space.gif" width="5" height="1">
 107         <input type=checkbox name='risk_suicide_nk'  >&nbsp;<b>Not Known</b>
 108         <img src="../../../images/space.gif" width="5" height="1">
 109         <input type=checkbox name='risk_suicide_io'  >&nbsp;<b>Ideation only</b>
 110         <img src="../../../images/space.gif" width="5" height="1">
 111         <input type=checkbox name='risk_suicide_plan'  >&nbsp;<b>Plan</b><br>
 112         <img src="../../../images/space.gif" width="100" height="1">
 113         <input type=checkbox name='risk_suicide_iwom'  >&nbsp;<b>Intent without means</b>
 114         <img src="../../../images/space.gif" width="5" height="1">
 115         <input type=checkbox name='risk_suicide_iwm'  >&nbsp;<b>Intent with means</b><br>
 116 <br>
 117 <b>Homocide:</b><br><input type=checkbox name='risk_homocide_na'  >&nbsp;<b>Not Assessed</b>
 118         <img src="../../../images/space.gif" width="5" height="1">
 119         <b>Behaviors:</b>
 120         <img src="../../../images/space.gif" width="5" height="1">
 121         <input type=checkbox name='risk_homocide_nk'  >&nbsp;<b>Not Known</b>
 122         <img src="../../../images/space.gif" width="5" height="1">
 123         <input type=checkbox name='risk_homocide_io'  >&nbsp;<b>Ideation only</b>
 124         <img src="../../../images/space.gif" width="5" height="1">
 125         <input type=checkbox name='risk_homocide_plan'  >&nbsp;<b>Plan</b><br>
 126         <img src="../../../images/space.gif" width="100" height="1">
 127         <input type=checkbox name='risk_homocide_iwom'  >&nbsp;<b>Intent without means</b>
 128         <img src="../../../images/space.gif" width="5" height="1">
 129         <input type=checkbox name='risk_homocide_iwm'  >&nbsp;<b>Intent with means</b><br>
 130 <br>
 131 <b>Compliance with treatment:</b><br><input type=checkbox name='risk_compliance_na'  >&nbsp;<b>Not Assessed</b>
 132         <img src="../../../images/space.gif" width="5" height="1">
 133         <input type=checkbox name='risk_compliance_fc'  >&nbsp;<b>Full compliance</b>
 134         <img src="../../../images/space.gif" width="5" height="1">
 135         <input type=checkbox name='risk_compliance_mc'  >&nbsp;<b>Minimal compliance</b>
 136         <img src="../../../images/space.gif" width="5" height="1">
 137         <input type=checkbox name='risk_compliance_moc'  >&nbsp;<b>Moderate compliance</b><br>
 138         <img src="../../../images/space.gif" width="100" height="1">
 139         <input type=checkbox name='risk_compliance_var'  >&nbsp;<b>Variable</b>
 140         <img src="../../../images/space.gif" width="5" height="1">
 141         <input type=checkbox name='risk_compliance_no'  >&nbsp;<b>Little or no compliance</b><br>
 142 <br>
 143 <b>Substance Abuse:</b><br><input type=checkbox name='risk_substance_na'  >&nbsp;<b>Not Assessed</b>
 144         <img src="../../../images/space.gif" width="5" height="1">
 145         <input type=checkbox name='risk_substance_none'  >&nbsp;<b>None/normal use:</b><br>
 146     <textarea cols=100 rows=1 wrap=virtual name="risk_normal_use" ></textarea><br>
 147         <input type=checkbox name='risk_substance_ou'  >&nbsp;<b>Overuse</b>
 148         <img src="../../../images/space.gif" width="5" height="1">
 149         <input type=checkbox name='risk_substance_dp'  >&nbsp;<b>Dependence</b>
 150         <img src="../../../images/space.gif" width="5" height="1">
 151         <input type=checkbox name='risk_substance_ur'  >&nbsp;<b>Unstable remission of abuse</b>
 152         <img src="../../../images/space.gif" width="5" height="1">
 153         <input type=checkbox name='risk_substance_ab'  >&nbsp;<b>Abuse</b><br>
 154 <br>
 155 <b>Current physical or sexual abuse:</b><br><input type=checkbox name='risk_sexual_na'  >&nbsp;<b>Not Assessed</b>
 156         <img src="../../../images/space.gif" width="5" height="1">
 157         <input type=checkbox name='risk_sexual_y'>&nbsp;<b>Yes</b>
 158         <img src="../../../images/space.gif" width="5" height="1">
 159         <input type=checkbox name='risk_sexual_n'>&nbsp;<b>No</b><br>
 160         <b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_sexual_ry'>&nbsp;<b>Yes</b>
 161         <img src="../../../images/space.gif" width="5" height="1">
 162         <input type=checkbox name='risk_sexual_rn'>&nbsp;<b>No</b>
 163         <img src="../../../images/space.gif" width="5" height="1">
 164         <b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_sexual_cv'>&nbsp;<b>victum</b>
 165         &nbsp;<input type=checkbox name='risk_sexual_cp'>&nbsp;<b>perpetrator</b><br>
 166         <input type=checkbox name='risk_sexual_b'>&nbsp;<b>Both</b>&nbsp;
 167         <img src="../../../images/space.gif" width="5" height="1">
 168         <input type=checkbox name='risk_sexual_nf'>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
 169 <br>
 170 <b>Current child/elder abuse:</b><br><input type=checkbox name='risk_neglect_na'  >&nbsp;<b>Not Assessed</b>
 171         <img src="../../../images/space.gif" width="5" height="1">
 172         <input type=checkbox name='risk_neglect_y'>&nbsp;<b>Yes</b>
 173         <img src="../../../images/space.gif" width="5" height="1">
 174         <input type=checkbox name='risk_neglect_n'>&nbsp;<b>No</b><br>
 175         <b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_neglect_ry'>&nbsp;<b>Yes</b>
 176         <img src="../../../images/space.gif" width="5" height="1">
 177         <input type=checkbox name='risk_neglect_rn'>&nbsp;<b>No</b>
 178         <img src="../../../images/space.gif" width="5" height="1">
 179         <b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_neglect_cv'>&nbsp;<b>victum</b>
 180         &nbsp;<input type=checkbox name='risk_neglect_cp'>&nbsp;<b>perpetrator</b><br>
 181         <input type=checkbox name='risk_neglect_cb'>&nbsp;<b>Both</b>&nbsp;
 182         <img src="../../../images/space.gif" width="5" height="1">
 183         <input type=checkbox name='risk_neglect_cn'>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
 184 <br>
 185
 186         <b>If risk exists:</b>&nbsp;client&nbsp;<input type=checkbox name='risk_exists_c'><b>can</b>&nbsp;
 187         <img src="../../../images/space.gif" width="5" height="1">
 188         <input type=checkbox name='risk_exists_cn'>&nbsp;<b>cannot</b>&nbsp;
 189         <b>meaningfully agree to a contract not to harm</b><br>
 190         <input type=checkbox name='risk_exists_s'>&nbsp;<b>self</b>
 191         <img src="../../../images/space.gif" width="5" height="1">
 192         <input type=checkbox name='risk_exists_o'>&nbsp;<b>others</b>
 193         <img src="../../../images/space.gif" width="5" height="1">
 194         <input type=checkbox name='risk_exists_b'>&nbsp;<b>both</b><br><br>
 195
 196     <b>Risk to community (criminal):</b><br>
 197     <textarea cols=100 rows=3 wrap=virtual name="risk_community" ></textarea><br>
 198
 199 <b><u>Assessment Recommendations:</u></b><br><br>
 200
 201 <b>Outpatient Psychotherapy:</b>
 202         <img src="../../../images/space.gif" width="5" height="1">
 203         <input type=checkbox name='recommendations_psy_i'>&nbsp;<b>Individual</b>
 204         <img src="../../../images/space.gif" width="5" height="1">
 205         <input type=checkbox name='recommendations_psy_f'>&nbsp;<b>Family</b>
 206         <img src="../../../images/space.gif" width="5" height="1">
 207         <input type=checkbox name='recommendations_psy_m'>&nbsp;<b>Marital/relational</b>
 208         <img src="../../../images/space.gif" width="5" height="1">
 209         <input type=checkbox name='recommendations_psy_o'>&nbsp;<b>Other</b><br>
 210     <textarea cols=100 rows=3 wrap=virtual name="recommendations_psy_notes" ></textarea><br>
 211
 212 <b>Date report sent to referral source:</b>
 213         <img src="../../../images/space.gif" width="5" height="1">
 214         <input type=text name='refer_date'>
 215         <img src="../../../images/space.gif" width="5" height="1">
 216         <b>Parent/Guardian:</b>
 217         <img src="../../../images/space.gif" width="5" height="1">
 218     <input type=text name='parent'>
 219 <br>
 220
 221 <b>Level of supervision needed:</b>
 222         <br>
 223         <textarea cols=100 rows=1 wrap=virtual name="supervision_level" ></textarea><br>
 224         <b>Type of program:</b><br>
 225         <textarea cols=100 rows=1 wrap=virtual name="supervision_type" ></textarea><br>
 226
 227 <b>Residential or long-term placement recommended:</b>
 228         <img src="../../../images/space.gif" width="5" height="1">
 229         <textarea cols=100 rows=1 wrap=virtual name="supervision_res" ></textarea><br>
 230         <b>Support services needed:</b><br>
 231         <textarea cols=100 rows=1 wrap=virtual name="supervision_services" ></textarea><br>
 232
 233         <input type=checkbox name='support_ps'>&nbsp;<b>Parenting skills/child management</b>
 234         <img src="../../../images/space.gif" width="5" height="1">
 235     <input type=checkbox name='support_cs'>&nbsp;<b>Communication skills</b>
 236         <img src="../../../images/space.gif" width="5" height="1">
 237     <input type=checkbox name='support_sm'>&nbsp;<b>Stress management</b><br>
 238
 239         <input type=checkbox name='support_a'>&nbsp;<b>Assertiveness</b>
 240         <img src="../../../images/space.gif" width="5" height="1">
 241     <input type=checkbox name='support_o'>&nbsp;<b>Other</b><br>
 242         <textarea cols=100 rows=1 wrap=virtual name="support_ol" ></textarea><br><br>
 243
 244 <b>Legal Services:</b>
 245         <img src="../../../images/space.gif" width="5" height="1">
 246     <input type=checkbox name='legal_op'>&nbsp;<b>Offender program</b>
 247         <img src="../../../images/space.gif" width="5" height="1">
 248     <input type=checkbox name='legal_so'>&nbsp;<b>Sex Offender Groups</b>
 249         <img src="../../../images/space.gif" width="5" height="1">
 250     <input type=checkbox name='legal_sa'>&nbsp;<b>Substance abuse</b><br>
 251
 252         <input type=checkbox name='legal_ve'>&nbsp;<b>Victum empathy group</b>
 253         <img src="../../../images/space.gif" width="5" height="1">
 254     <input type=checkbox name='legal_ad'>&nbsp;<b>Referral to advocate</b>
 255         <img src="../../../images/space.gif" width="5" height="1">
 256     <input type=text name='legal_adl'>
 257         <img src="../../../images/space.gif" width="5" height="1"><br>
 258     <input type=checkbox name='legal_o'>&nbsp;<b>Other:</b>
 259
 260         <br>
 261
 262     <b>Other:</b><br>
 263         <textarea cols=100 rows=1 wrap=virtual name="legal_ol" ></textarea><br><br>
 264
 265 <b><u>Referrals for Continuing Services</u></b><br><br>
 266
 267 <b>Psychiatric Evaluation Psychotropic Medications:</b><br>
 268         <textarea cols=100 rows=2 wrap=virtual name="referrals_pepm" ></textarea><br><br>
 269
 270 <b>Medical Care:</b><br>
 271         <textarea cols=100 rows=2 wrap=virtual name="referrals_mc" ></textarea><br><br>
 272
 273 <b>Educational/vocational services:</b><br>
 274         <textarea cols=100 rows=2 wrap=virtual name="referrals_vt" ></textarea><br><br>
 275
 276 <b>Other:</b><br>
 277         <textarea cols=100 rows=2 wrap=virtual name="referrals_o" ></textarea><br><br>
 278
 279 <b>Current use of resources/services from other community agencies:</b><br>
 280         <textarea cols=100 rows=2 wrap=virtual name="referrals_cu" ></textarea><br><br>
 281
 282 <b>Documents to be obtainded (Release of Information Required):</b><br>
 283         <textarea cols=100 rows=2 wrap=virtual name="referrals_docs" ></textarea><br><br>
 284
 285 <b>Other needed resources and services:</b><br>
 286         <textarea cols=100 rows=2 wrap=virtual name="referrals_or" ></textarea><br><br>
 287
 288
 289 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 290 <img src="../../../images/space.gif" width="5" height="1">
 291 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
 292  onclick="top.restoreSession()">[Don't Save]</a></center>
 293 <br>
 294 </form>
 295 <?php
 296 formFooter();
 297 ?>