Form 1 Mental Health Assessment Form

Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness

ORR Mental Health Assessment Form_0970-0509_Clean

Mental Health Assessment Form - Reporting Time

OMB: 0970-0509

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OMB Control No: 0970-0509

Expiration date: 9/30/2026




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: ____ / ____ / _____,

  • Approximate

  • Exact

  • Contraceptive use, specify: ______________________

  • 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 9/30/2026. 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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2023-12-11

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