1001 Biopsychosocial Assessment (PIHP) (Handwritten)

Thumb Alliance Prepaid Inpatient Health Plan
BIOPSYCHOSOCIAL ASSESSMENT
CONSUMER INFORMATION
Consumer Name:
Case #:
Assessment Date:
Start Time:
Stop Time:
PRESENTING PROBLEMS
Accommodations necessary to complete assessment: Explain:
What brings you in for services?
Have you ever had these difficulties before?
Yes
No
When and how long:
How have you tried to cope with these difficulties?
Do you require assistance linking with any of the following?

N/A
DHS
Describe:
Court System
Schools
SSA
Vocational
PERSONAL/FAMILY INFORMATION
Mothers name:
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Other
Consumer Name:
Case #:
Mothers relationship to consumer (biological, step, adopted, foster):

Occupation:
If deceased, then date (or unknown):
Fathers name:
Fathers relationship to consumer (biological, step, adopted, foster):
Occupation:
If deceased, then date (or unknown):
Are your parents:
Married
Separated
Living Together/Unmarried
Never Married
Unknown
Divorced
Other
Comments:
List Siblings:
Significant Other:
Have you ever been married?
How many times?
Yes
No
Are you currently involved in a significant relationship?
Yes
No
If currently married or involved in significant relationship, how long and what is the status of the
relationship?
Are you pregnant or do you suspect you may be pregnant?
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Yes
No
Consumer Name:
Case #:
Children:
Childs Name
Age
Consumer has no children

Who Does
Childs
the Child
Gender
Live with
Male
Female
Male
Female
Male
Female
Male
Female
Yes
No
Yes
No
Yes
No
Yes
No
How would you describe your (past/present) relationship with your

Father:
Mother:
Children:
Siblings:
Friends:
Other:
In your relationships or family is there or has there ever been (Check all that apply):
Verbal Abuse
Physical Abuse
Sexual Abuse
Neglect
Protective Services Involvement
N/A
Describe:
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Biological Child
Consumer Name:
Case #:
Does faith or religion play a part in your life?

Yes
No
Describe:
What cultural/ethnic/other people or groups have influenced you?

(e.g. race, ethnicity, socio-economic group, language issue, family tradition, age group, educational
background, employment-vocation-avocation, homelessness, sexual orientation, literacy, physical disability,
mental illness, developmental disability, club or organization membership, etc.
Have you ever been a member of any clubs or organizations?

Yes
No
Have you ever been a member of any clubs or organizations?

Yes
No
If yes, which one(s)?
Page 4 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
PERSONAL/FAMILY INFORMATION:
Need/Desire/Concern
No Need/Desire/Concern
CHILDHOOD
At what age did the following developmental milestones occur? (Optional for adults)
Unknown
Not Applicable
Walk:
Age:
Within developmental milestones?
Yes
No; if no, explain:
Talk:
Age:
Yes
No; if no, explain:
Toilet Trained:
Age:
Yes
No; if no, explain:
Were there any complications at birth or with pregnancy?

Explain:
How would you describe your childhood?

Explain:
Good
Yes
Fair
Did you ever live outside your parents home for an extended time?
Explain:
Page 5 of 26
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Rev: 5/11
No
Unknown
Poor
Yes
No
Unknown
Consumer Name:
Other information about your childhood:

Explain:
Page 6 of 26
Form #1001
Rev: 5/11
Case #:
Consumer Name:
Case #:
CHILDHOOD:
Need/Desire/Concern
RESIDENTIAL
Residential Living Arrangement
Homeless on the street or in a shelter for the homeless.
Living in a private residence with natural or adoptive family member(s).
Living in a private residence not owned by the CMHSP or the contracted provider, alone or with spouse
or non-relative(s).
Foster Family Home
Specialized Residential Home
General Residential Home
Prison/Jail/Juvenile Detention Center
Nursing Care Facility
Institutional Setting (Congregate Care Facility, Boarding School, Child Caring Institutions, State
Facilities).
Supported Independence Program (Lease is held by CMHSP or Provider).
Number of beds in residential setting:
Unknown
1-3
4-6
7-15
16+
Are you happy with your current living arrangement?

Yes
No
Explain:
RESIDENTIAL INFORMATION:
Need/Desire/Concern
Page 7 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
EDUCATION
Highest Level Attended:
Completed less than high school
Completed special education, high school or GED
In school Kindergarten through 12th grade
Highest grade: (Select a grade)
K Kindergarten
01-First Grade
02-Second Grade
04-Fourth Grade
05-Fifth Grade
06-Sixth Grade
08-Eighth Grade
09-Ninth Grade
10-Tenth Grade
12-Twelfth Grade
In Training Program
In Special Education
Emotionally Impaired (EI)
Cognitive Impaired (CI)
Severely Multiply Impaired (SXI)
Autistic Impaired (AI)
Health Impaired (HI)
Not Applicable
Attended or is attending Undergraduate College
College Graduate
03-Third Grade
07-Seventh Grade
11-Eleventh Grade
School, Name and Location:

Number of years of education (enter 0-25): e.g. 4 years of college = 16
Are you currently in Training/Education?
Contact person:
Yes
No
Have you ever had problems in school with the following?

None
Expelled
Suspended
Poor Conduct
Truancy
How would you describe your school experience?
Fair
Are you interested in continuing your education?

Explain:
Good
Yes
No
EDUCATION INFORMATION:
Need/Desire/Concern
DAILY LIVING SKILLS

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Form #1001
Rev: 5/11
Other
Poor
Consumer Name:
Case #:
Please rank your skills in the following areas as they relate to your current living situation.
Area
1-Independent
2-Guide/Direct
3-Provide/Assist
4-Not Age
Appropriate
Eating/Feeding:
Toileting:
Bathing:
Dressing:
Grooming:
Transferring:
Ambulation/Mobility:
Medication Administration:
Laundry:
Cooking:
Transportation:
Housecleaning:
Paying Bills:
Leisure/Recreation:
Community Access:
How do you fill your leisure time?
Explain any current assistance by family members, friends and/or providers for the above identified areas
including leisure:
Are there adequate assets, income and/or insurance(s) to meet your needs?
Explain:
DAILY LIVING SKILLS:

Need/Desire/Concern
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Form #1001
Rev: 5/11
Yes
No
Consumer Name:
Case #:
MILITARY
Section does not apply
Have you been involved in the military?
Yes
No
When did you serve?

Branch:
Rank:
Ever reduced in rank?
Yes
No
How would you describe your military experience?

Good
Fair
Poor
Discharge Status:
Honorable
Dishonorable
Medical
Did you experience combat?
Yes
No
Comments:
General
MILITARY
Need/Desire/Concern
EMPLOYMENT
Employment Status:
Employed full time (30 hours or more per week) competitively or self employed
Employed part time (less than 30 hours per week) competitively or self employed
Unemployed looking for work, and/or on lay-off from job
Not in the competitive labor force
Includes: homemaker, student age 18 and over, day program participant, resident or inmate of an
institution (including nursing home)
Retired from work
Sheltered workshop or work services participant in non-integrated setting
Not applicable to the person (e.g., child under 18)
In supported employment only
In supported employment and competitive employment
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Form #1001
Rev: 5/11
Consumer Name:
Case #:
In unpaid work
If employed, occupation:
Minimum wage: Yes
No
N/A
Work Experience:
Where do you work?
How many hours per week?
How long at current paid or volunteer job?
Yrs
Months
How many paid or volunteer jobs have you had in the past 2 years?
Have you ever had problems at paid or volunteer work?
Are you satisfied with your current paid or volunteer work?
Yes
Yes
No
No
If you are not working, are you interested in pursuing any kind of community employment or volunteer
work?
Yes
No
Explain:
EMPLOYMENT
Need/Desire/Concern
Page 11 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
Primary Guardian Information:

Guardian Name:
Address:
Phone Work:
Type of Guardianship:
GUARDIAN/LEGAL
Phone Home:
Family Guardian
Parental
Permanent State Wardship
Public Guardian
Temporary Wardship
Relationship to Consumer:
Co-Guardian Information:
Co-Guardian Name:
Address:
Phone Work:
Type of Guardianship:
Phone Home:
Family Guardian
Parental
Permanent State Wardship
Public Guardian
Temporary Wardship
Relationship to Consumer:
Additional Guardian Notes:
Corrections Related Status:

Not under jurisdiction of a corrections or law enforcement program
In Prison
In Jail
Paroled from Prison
Probation from Jail
Juvenile Detention Center
Court Supervision
Awaiting Sentencing
Awaiting Trial
Arrested and Booked
Minor (Under 18): Referred by Court
Refused to give information
Diverted from Arrest or Booking
Does someone have power of attorney for you?
If yes, who:
Yes
No
Is there someone who handles or assists you with your finances?

If yes, who:
Are you court ordered for treatment?
Yes
Yes
No
No
Are you currently facing criminal charges:

Yes
No
Have you been or are you currently on probation, parole, work release:
Comments:
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Rev: 5/11
Yes
No
Consumer Name:
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Case #:
Consumer Name:
Case #:
Name of parole or probation officer:

Telephone number:
What were you charged with when arrested:
How many times have you been convicted?

Number of arrests/convictions related to alcohol/drugs:
Are you involved in any non-criminal cases (e.g., divorce, custody, bankruptcy, eviction)?
Yes
No
Comments:
GUARDIAN/LEGAL:
Need/Desire/Concern
HEALTH & OTHER CONDITIONS (To be completed for ALL POPULATIONS):

Hearing
Ability to hear (with hearing appliance normally used)
Adequate-No difficulty in normal conversation, social interaction, listening to TV
Minimal difficulty-Difficulty in some environments (e.g., when person speaks softly or is more than 6
feet away)
Moderate difficulty-Problem hearing normal conversation, requires quiet setting
to hear well
Severe difficulty-Difficulty in all situations (e.g., speaker has to talk loudly or speak very slowly; or
person reports that all speech is mumbled)
No hearing
Hearing aid used
Yes
No
Vision
Ability to see in adequate light (with glasses or with other visual appliance normally used
Adequate-Sees fine detail, including regular print in newspapers/books or small
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Form #1001
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Consumer Name:
Case #:
items in pictures
Minimal difficulty-Sees large print, but not regular print in newspapers/books or cannot identify large
objects in pictures
Moderate difficulty-Limited vision; not able to see newspaper headlines or small
items in pictures, but can identify objects in his/her environment
Severe difficulty-Object identification in question, but the persons eyes appear to follow objects, or the
person sees only light, colors, shapes
No vision
Visual appliance used
Yes
No
Health Conditions
Indicate whether or not the individual had the presence of each of the following health conditions, as
reported by the individual, a health care professional or family member, in the past 12 months.
Pneumonia (2 or more times within the past 12 months)-including Aspiration Pneumonia
Never present
History of condition, but not treated for the condition within the past 12 months
Treated for the condition within the past 12 months
Information unavailable
Asthma
Never present
History of condition, but not treated within the past 12 months
Upper Respiratory Infections (These infections may affect the throat, nasal cavity, sinuses, larynx or
bronchi. (3 or more times within the past 12 months)
Never present
Gastroesophageal Reflux, or GERD
Never present
Chronic Bowel Impactions
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Form #1001
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Consumer Name:
Case #:
Never present
Seizure disorder or Epilepsy
Never present
Treated for the condition within the past 12 months and seizure free
Treated for the condition within the past 12 months, but still experiencing occasional seizures (less
than one per month)
Treated for this condition within the past 12 months, but still experiencing frequent seizures
Progressive neurological disease, include dementia, Alzheimers and Parkinsons disease.
Not present
Diabetes, include both Diabetes Type I and Diabetes Type II-(Insulin Dependent)
Never present
Hypertension
Never present
Treated for condition within the past 12 months and blood pressure is stable
Treated for condition within the past 12 months, but blood pressure remains high or unstable
Information is unavailable
Obesity
Not present
Medical diagnosis of obesity present or Body Mass Index (BMI) >30
(if 30 lbs. or more overweight)
Page 16 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
MEDICAL/MEDICATIONS
Do you have a primary care physician?
Yes
No
Qualified Health Plan (QHP):
Great Lakes Health Plan
Health Plan of Michigan
Health Plus
Partners
McLaren Health Plan
Midwest Health Plan
Molina Healthcare of MI
If Yes, Physician Name/Address/Phone Number:
Date last seen:
If you do not have a primary care physician, do you want or need help finding one?
Yes
CMHSP Prescribed Medications:

Source
Prescribed By
QTY/Refills
Instructions:
Instructions
D/C
Drug
Name/Strength
Other Medications (Consumer self report):

Source
Drug Name
Strength
Do you frequently miss doses?
Yes
Do you feel your medications are helpful?

Explain:
No
N/A
Yes
No
N/A
Allergies to medication?
Check here if you would like to show this as a Health and Safety warning.
Date of last physical: (Actual/Approximate/Unknown)
Page 17 of 26
Form #1001
Rev: 5/11
No
Consumer Name:
Case #:
Major Illnesses/Surgeries:
Accidents/Major Injuries:
Hospitalizations (psychiatric):
Do you have a Psychiatric Advanced Directive?
Yes
No
Other pertinent medical information (e.g., nutritional):
Medical/Medications
Need/Desire/Concern
HEALTH AND SAFETY

Indicate the need for supports in any of the following health and safety domains:
N/A
Danger to Self (within last 7 days)
Danger to Others (within last 7 days)
(A Lethality Assessment is required if either of these boxes is checked and evaluate if Clinical
Assessment is needed.)
Concerns Related to Judgment
Medical Concerns
Safety in the Community
Medication Concerns
Safety in the Home
Safety in Relationships
Anger Management
Other
Other/Comments:
How are your health and safety needs being met?
Page 18 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
HEALTH AND SAFETY:

Need/Desire/Concern
Section Not Applicable
Danger To
LETHALITY ASSESSMENT
Past
Ideation
Intent
Plan
Means
Action
None
Current
Ideation
Intent
Plan
Means
Action
None
Others
Ideation
Intent
Plan
Means
Action
None
Ideation
Intent
Plan
Means
Action
None
Property
Ideation
Intent
Plan
Means
Action
None
Ideation
Intent
Plan
Means
Action
None
Self
Explain:
Explain:
Explain:
Page 19 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
MENTAL HEALTH AND SUD HISTORY

Have you had Mental Health Treatment before?
Explain:
Yes
Have you had SUD Treatment before?

Explain:
No, consumer denies SUD Treatmentt
Yes
No, consumer denies Mental Health Treatment
Is there a Family History of Mental Illness, Developmental Disability and/or Substance Use Disorder?
No Family History
Family Member
MI
DD
SUD
Diagnosis
SUD Sections Not Applicable

SUD Questions
In the past year, have you ever drank or used drugs more than you meant to?
Have you ever felt you wanted or needed to cut down on your drinking or drug use in the last year?
Has anyone objected to your drinking or drug use?
Have you ever used alcohol or drugs to relieve emotional discomfort such as sadness, anger, or
boredom?
Have people annoyed you by criticizing your drug use?
Have you ever felt bad or guilty about your drug use?
Have you ever used drugs first thing in the morning to steady your nerves or get rid of a hangover?
Any history of overdoes?
Any history of blackouts?
Yes
Yes
No
No
Any history of seizures, DTs, hallucinations?
Yes
No
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Form #1001
Rev: 5/11
Yes
No
Consumer Name:
Case #:
(A yes answer to any of these questions is likely to indicate drug abuse and should spur further investigation)
Complete ASAM worksheet if applicable.
Comments:
Narrative:
SUD CHART
Section applicable:
If yes, please complete SUD Chart form #1018.
No
Mental Health and SUD History:
Need/Desire/Concern
SUD IMPACT QUESTIONS

Section not applicable
How does your current living environment impact your substance use? (Location, support system, at risk
issue)
What are the past recovery attempts? Longest period of recovery? How was this achieved?
Did you have a relapse? What triggered the relapse? What will be different in treatment this time? Any use
of Antabuse, Methadone, Maltraxone or Revia?
What are the supports experienced in the past? AA/NA meetings, sponsor, support groups, therapy
support, group or church?
Page 21 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
Do you hold a current drivers license?

Do you have transportation?
In what areas of functioning have you experience consequences? (physical, mental, emotional, legal,
financial, social or spiritual)
Have you attended Raves or similar parties?
Have you engaged in high risk sexual behavior (number of sexual partners, use of barriers or condoms)? If yes,
when did you first become sexually active?
Are you more sexually active when using mood altering chemicals?
Have you engaged in other types of risk taking activities?
Have you ever run away from your home?
SUD IMPACT QUESTIONS:

Need/Desire/Concern
Mental Status
Mental Status
Appearance:
Comments:
Remarkable
Unremarkable
Page 22 of 26
Form #1001
Rev: 5/11
Consumer Name:
Attitude:
Comments:
Behavior:
Comments:
Case #:
Remarkable
Remarkable
Mood/Affect:
Comments:
Orientation:
Comments:
Unremarkable
Remarkable
Motor Activity:
Comments:
Judgment:
Comments:
Unremarkable
Unremarkable
Remarkable
Remarkable
Remarkable
Insight:
Remarkable
Comments:
Thought Process:
Comments:
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Remarkable
Unremarkable
Abstract Reasoning:
Comments:
Remarkable
Unremarkable
Language Function:
Comments:
Remarkable
Unremarkable
Memory:
Comments:
Remarkable
Unremarkable
Page 23 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
Cognitive Functioning:
Remarkable
Unremarkable
Comments:
Perception:
Remarkable
Unremarkable
Comments:
Comments:
MENTAL STATUS:
Need/Desire/Concern
DIAGNOSIS
Axis I (ICD-9 and DSM-IV):
Axis II (ICD-9 and DSM-IV):
Axis III:
Axis IV:
Economic problems
Problem with primary support group
Problem accessing healthcare
Problem related to social environment
Educational problems
Problem related to interaction with
legal system
Occupational problems
Housing problems
Other psychological and environmental
problem
Axis V: Current GAF
Date:
Diagnostic Summary:
Page 24 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
Diagnosis made by:
SERVICE ELIGIBILITY CRITERIA
Please complete the applicable Service Eligibility Criteria form.

Adults with Mental Illness: Form # 1028
Individuals with Developmental Disabilities: Form # 1029
DD Proxy Measures: Form # 1030
Children and Adolescents with Serious Emotional Disturbance Age 7-17: Form # 1031
SERVICES/SUPPORT RECOMMENDATIONS
Assessment of consumer/natural support system to manage involvement with systems and ensure necessary
supports:
Independent
Strong Abilities
Moderate Abilities
Limited Abilities
Recommendations regarding Case Management /Supports Coordination:
Necessary
Unnecessary
Rationale for assessed Case Management/Supports Coordination:
Strengths:
Recommendations:
The following domains have been identified as a need/desire/concern.
The above domains will be discussed during the Person Centered Planning process to determine what resources might be
available to address the area, what, if any, CMH/PIHP service might be medically necessary, as well as the amount, duration and
scope of such service.
N/A, explanation (include referral, not eligible, etc.):

Comments:
Page 25 of 26
Form #1001
Rev: 5/11
Consumer Name:
Case #:
Staff Signature
Date
Supervisor Signature if applicable
Date
Page 26 of 26
Form #1001
Rev: 5/11

1001 Biopsychosocial Assessment (PIHP) (Handwritten)

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1001 Biopsychosocial Assessment (PIHP) (Handwritten)

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Thumb Alliance Prepaid Inpatient Health Plan

Have you ever had these difficulties before?

When and how long:

How have you tried to cope with these difficulties?

Do you require assistance linking with any of the following?

Mothers relationship to consumer (biological, step, adopted, foster):

Are you currently involved in a significant relationship?

Consumer has no children

How would you describe your (past/present) relationship with your

Does faith or religion play a part in your life?

What cultural/ethnic/other people or groups have influenced you?

Have you ever been a member of any clubs or organizations?

Have you ever been a member of any clubs or organizations?

No; if no, explain:

No; if no, explain:

No; if no, explain:

Were there any complications at birth or with pregnancy?

How would you describe your childhood?

Other information about your childhood:

Are you happy with your current living arrangement?

School, Name and Location:

Have you ever had problems in school with the following?

How would you describe your school experience?

Are you interested in continuing your education?

DAILY LIVING SKILLS

How do you fill your leisure time?

DAILY LIVING SKILLS:

When did you serve?

How would you describe your military experience?

Primary Guardian Information:

Corrections Related Status:

Is there someone who handles or assists you with your finances?

Are you currently facing criminal charges:

Name of parole or probation officer:

How many times have you been convicted?

HEALTH & OTHER CONDITIONS (To be completed for ALL POPULATIONS):

CMHSP Prescribed Medications:

Other Medications (Consumer self report):

Do you frequently miss doses?

Do you feel your medications are helpful?

Do you have a Psychiatric Advanced Directive?

Other pertinent medical information (e.g., nutritional):

HEALTH AND SAFETY

How are your health and safety needs being met?

HEALTH AND SAFETY:

MENTAL HEALTH AND SUD HISTORY

Have you had SUD Treatment before?

No, consumer denies SUD Treatmentt

No, consumer denies Mental Health Treatment

SUD Sections Not Applicable

Any history of seizures, DTs, hallucinations?

SUD IMPACT QUESTIONS

Do you hold a current drivers license?

Have you engaged in other types of risk taking activities?

Have you ever run away from your home?

SUD IMPACT QUESTIONS:

Diagnosis made by:

SERVICE ELIGIBILITY CRITERIA

Please complete the applicable Service Eligibility Criteria form.

Rationale for assessed Case Management/Supports Coordination:

N/A, explanation (include referral, not eligible, etc.):

Supervisor Signature if applicable