Client Legal Name *

DOB *

MRN

Preferred name / pronouns

Guardian / Legal custodian

Insurance / Medicaid ID

Referral source

Reason for referral (source)

Tip: this form auto-saves to your browser. Use the buttons at the bottom to navigate, save, or print.

Primary concerns (youth/guardian words) *

Onset

Current severity

Modality

Functional impact (home/school/peers/community)

Client goals in own words

Trauma exposures

ACES Count

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

Violence/other risks

Protective factors

Appearance

Behavior

Attitude

Speech

Mood

Affect

Thought process

Thought content

Attention/Concentration

Insight/Judgment

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

#	Domain	Score (1–7)	Note

Average: —

Targets (≤4): —

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

Primary diagnosis (DSM-5-TR)

ICD-10

Secondary diagnosis

ICD-10

Psychosocial/SDOH (Z-codes)

Formulation (biopsychosocial)

Medical necessity & least restrictive justification

Recommended services

Service intensity/frequency

Clinician Name/Credentials *

Clinician Signature *

Date *

Client/Guardian Name

Client/Guardian Signature

Date

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

Comprehensive Needs Assessment