Administrative Information

Client Legal Name *

DOB *

MRN

Preferred name / pronouns

Guardian / Legal custodian

Insurance / Medicaid ID

Referral source

Reason for referral (source)

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Presenting Concerns

Primary concerns (youth/guardian words) *

Onset

Current severity

Modality

Functional impact (home/school/peers/community)

Client goals in own words

Trauma & Safety Assessment

Trauma exposures

Domestic Violence

Community Violence

Abuse/Neglect

Loss/Separation

Other

ACES Count

Suicide risk (SAFE-T/C-SSRS notes)

Violence/other risks

Protective factors

Mental Status Exam

Appearance

Behavior

Attitude

Speech

Mood

Affect

Thought process

Thought content

Attention/Concentration

Insight/Judgment

DLA-20 Assessment

Rate past 30 days. 1=Unable • 3=Significant difficulty • 5=Adequate • 7=Optimal.

#	Domain	Score (1–7)	Note

Average: —

Targets (≤4): —

CANS Assessment

Action levels: 0=No need • 1=Watch • 2=Action • 3=Immediate. Strengths: 0=Centerpiece • 1=Useful • 2=Build • 3=No strength.

EMDR Target Planning (Cluster Method)

Mapping the "Cluster" of memories that share a core Negative Belief.

Core Negative Belief (NC)

1. THE PAST (Roots)

Touchstone (Earliest) Worst Incident

2. THE PRESENT (Triggers)

Current Triggers (List 3)

3. THE FUTURE (Goal)

Positive Belief (PC) Future Template

Target Sequencing Strategy

Dissociation Screen (DES Score)

Diagnosis & Plan

Primary diagnosis (DSM-5-TR)

ICD-10

Secondary diagnosis

ICD-10

Psychosocial/SDOH (Z-codes)

Formulation (biopsychosocial)

Medical necessity & least restrictive justification

Recommended services

Outpatient

IIH

MH Skill-Building

Case Mgmt

Psych Eval/Med

Service intensity/frequency

Signatures

Clinician Name/Credentials *

Clinician Signature *

Date *

Client/Guardian Name

Client/Guardian Signature

Date

Telehealth sessions: document client location, privacy, emergency contact in progress notes.

Clinical Comprehensive Assessment