Form 1 Mental Health Assessment Form

OMB Control No: 0970-0466

Expiration date: XX/XX/XXXX

Mental Health Assessment Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Gender:

Date evaluated:

Time evaluated:

Primary language: _______________________________

Who provided appropriate language services for child during evaluation?

HCP fluent in child’s primary language

Trained interpreter

Not provided

Evaluating Healthcare Provider (HCP)

Name: MD / DO / PA / NP / PhD / PsyD

Phone number:

Clinic or Practice:

Street address:

City/Town:

State:

Location where child received care (e.g., Psychiatrist/Psychiatric NP or PA visit, Psychologist visit):

Program

Program name:

Program Staff Member Present During Exam with HCP

Reason for visit:

Initial specialist visit

Follow-up specialist visit

History and Assessment

Vital Signs

Temperature (T)

Heart Rate (HR)

BP (> 3 yrs)

Resp Rate (RR)

Height (HT)

Weight (WT)

BMI (>2 yrs)

BMI %ile

0C

cm

kg

Allergies:

No

Yes, specify below:

Food

Medication

Environmental

Allergen

Reaction

Medical & Mental Health History (including dates & locations of care):

Surgeries: _______________________________________________________________________________________________________________________

Hospitalizations: __________________________________________________________________________________________________________________

Chronic/Underlying conditions: ______________________________________________________________________________________________________

Family history: ___________________________________________________________________________________________________________________

Medications, (dosage frequency & dates):

Past: ____________________________________________________________________________________________________

Current: _________________________________________________________________________________________________

Reproductive history (complete for anatomically female UC who have started menarche):

Date of LMP: ____ / ____ / _____, if unknown, months since LMP: ______

Current contraceptive use

Currently breastfeeding

Abuse:

Yes, specify

Denied, with no obvious signs

Denied, but obvious signs present

Unknown

Verbal:

Emotional:

Physical:

Sexual:

Other victimization (e.g., gang, bullying, crime):

Substance use:

Yes, specify

Denied, with no obvious signs/symptoms

Denied, but obvious signs/symptoms present

Unknown

Alcohol

Tobacco / Nicotine

Marijuana

Injection drugs

Other substances

Specify substance(s)

N/A

Frequency/Quantity

Date of last use

Review of Systems (ROS) and Mental Status Exam (MSE)

Were any mental health signs/symptoms reported by the child or observed by program staff or HCP?

No

Yes, specify below:

Feels empty, hopeless, sad, numb more often than not

Engages in self-harm

Other:

Feels constantly worried, anxious, nervous more often than not

Feels easily annoyed or irritated

Has trouble concentrating, restless, too many thoughts

Relives traumatic events from the past

Experiences mood swings, from very high to very low

Feels afraid, easily startled, jumpy

Hears voices or sees things others do not see (hallucinations)

Thoughts of hurting self, would be better dead

Has trouble eating, sleeping

Thoughts of hurting others

Has nightmares

Can child attribute feelings to a specific reason(s)?

No

Yes, specify: _________________________________________________________________

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Brief Mental Status Exam (MSE)
	Normal			Abnormal, specify:
Appearance	Normal grooming & hygiene
Attitude	Calm & cooperative
Behavior	No unusual movements or psychomotor changes
Speech	Normal rate/tone/volume without pressure
Affect	Reactive & mood congruent; good range
Mood	Euthymic
Thought processes	Goal-directed & logical
Thought content	Not passive/active suicidal/homicidal
Perception	No hallucinations or delusions during interview
Orientation	Oriented time/place/person/ self
Memory/ Concentration	Short and long term intact
Insight/Judgement	Good	Fair	Poor

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Diagnosis and Plan

Diagnosis: Child with complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC) or referrals needed:

• No

• Yes

If Yes, check all diagnoses that apply. Specify in the space provided, where indicated.

DSM:

• Acute stress disorder/PTSD

• ADHD

• Adjustment disorder

• Autism

• Bipolar disorder

• Conduct disorder

• Eating disorder

• Generalized anxiety disorder

• Major depressive disorder

• Oppositional defiant disorder

• Panic disorder

• Primary psychotic disorder

• Other: _______________________________________

Medical:

Plan: Check all that apply and specify where indicated. Please provide copies of office notes and lab/imaging results to program staff.

• Age-appropriate anticipatory guidance discussed and/or handout given

• Child educated on healthcare services received and treatment recommendations

• Labs/imaging ordered/performed

• Medications administered/prescribed:

Medication Name	Reason	Date Started	Expected end date	Dose	Directions	Psychotropic
						No	Yes
						No	Yes
						No	Yes

• Child has special healthcare needs that require accommodation while admitted in ORR care; specify condition/reason, time frame and frequency:

• Onsite care provider clinician evaluation: _________________________________________________________________________________________

• Increased level of supervision for mental health concern: ____________________________________________________________________________

• Placement at a residential treatment center (RTC)¹: _________________________________________________________________________________

• Assistance with daily living activities: ____________________________________________________________________________________________

• Other: _____________________________________________________________________________________________________________________

• Child has/may have an ADA disability: ______________________________________________________________________________________________

• Child has health concerns that require follow-up services; specify needs and time frame by when services should occur:

• Return clinic: _______________________________________________________________________________________________________________

• Mental health specialist evaluation: _____________________________________________________________________________________________

• Other, specify: ______________________________________________________________________________________________________________

Child cleared to travel:

• Yes, with no restrictions

• Yes, with restrictions (e.g., ground travel, travel safety plan): ______________________________________________________________

• No, reason: ______________________________________________________________________________________________________

Recommendations from Healthcare Provider / Additional Information

Recommendations from Healthcare Provider / Additional Information

Healthcare Provider Signature: ______________________________________________________________ Date: _______ / ______ / __________

Healthcare Provider Printed Name: ___________________________________________________________

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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 11 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.

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1 Requires the recommendation of a psychiatrist or clinical psychologist