Submit this form by emailing it to your mental health provider or faxing it to their office. Alternatively, you can use an online submission form if available. Check with your provider for specific submission instructions. Ensure all fields are completed accurately before submission.

Important dates for this form in 2024 and 2025 include annual review deadlines and submission dates for mental health assessments. Check with your provider for specific dates.

The purpose of the Mental Health Plan Assessment Form is to evaluate a client's mental health status and needs. It assists mental health professionals in creating appropriate treatment plans. By gathering comprehensive information, the form ensures a thorough assessment and effective care.

• 1. Date: The date the form is completed.
• 2. Provider: The name of the mental health provider.
• 3. Phone: The contact number of the provider.
• 4. Provider Office Address: The office address of the provider.
• 5. Client Name: The name of the client receiving services.
• 6. Consent to treat given by: Includes options for who provided consent for treatment.
• 7. Referral: Indicates the source of the referral.
• 8. D.O.B.: Date of birth of the client.
• 9. SSN: Social Security Number of the client.
• 10. Parent/Guardian/Conservator: Information about the client's legal guardian.
• 11. Living Arrangement: Options for the client's current living arrangement.
• 12. Ethnicity: The client's ethnic background.
• 13. Emergency Contact: Details of the client's emergency contact.
• 14. Language Preferred for Services: The preferred language for receiving services.
• 15. Presenting Problem: Details about the nature and history of the client's presenting problem.
• 16. Risk Assessment: Sections to evaluate the client's risk of harm to self and others.
• 17. Client Strengths: Identifies the strengths of the client.
• 18. Culture/Diversity: Assesses unique aspects of the client including culture, background, and sexual orientation.
• 19. Psychiatric History: Details about the client's psychiatric history including medications and past treatments.

Failure to submit this form may result in delays in care or inadequate treatment planning. It is crucial to complete and submit the form on time.

• Delays in Care: Without the form, the client may experience delays in receiving necessary mental health services.
• Inadequate Treatment Planning: Incomplete information can lead to insufficient or inappropriate treatment plans.

• 1. Initial Assessment: Complete this form during the initial mental health assessment.
• 2. Treatment Planning: Use the form to gather information for creating a treatment plan.
• 3. Risk Evaluation: Assess risks of harm to self or others using this form.