Medicare Recommended Geriatric Assessments
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GerontologyA Training Resource By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Overview of Mental Health Assessments for Medicare Treatment of Aging Seniors
Medicare requires a complete set of assessments for both (1) Facility Based Residents Medicare Clients and and (2) Home Based in the community Medicare Clients. These assessments can be utilized in Residential Settings (Independent Living, Assisted Living, Nursing Home - Rehabilitation Center, or Memory unit) and used with independent living clients out in the community.
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MIPS QUALITY MEASURES
All MIPS measures are reported once per year during the Diagnostic Interview. If you have been seeing a patient in the previous year and continue in the new year, you should perform a new 90791 in January.
In addition, every clinician who sees a patient for the FIRST time should perform her or his own 90791 visit for the patient at the start of treatment. This is true for new patients who are assigned or transferred to you from other clinicians. It also applies to any patients you have seen previously who have been re-referred for a new episode of care. This establishes your current and full understanding of the case before proceeding to ongoing psychotherapy or behavior management services.Therapists who are referred patients for capacity evaluation or neuropsychological testing services must still begin services by completing a 90791 and the required quality measures. This helps build a rationale for testing (or rules out the need for testing) at the current time.
Below are the MIPS Quality Measures. The acceptable “findings” (G codes) you may select, as well as practical tips on how to complete the work in our treatment setting, are provided for each measure.
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Brief Interview for Mental Status (BIMS)
Part 1: Repetition of Three Words
Ask resident: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue and bed. Now tell me the three words."
Number of words repeated after first attempt:
_ 0. None _ 1. One _ 2. Two _ 3. Three
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture'). You may repeat the words up to two more times.
Part 2: Temporal Orientation (orientation to month, year and day)
Ask resident: "Please tell me what year it is right now."
Able to report correct year
___ 0 Missed by > 5 years,
___ 1 Missed by 2-5 years
___ 2 Missed by 1 year
___ 3 Correct
Ask resident: "What month are we in right now?"
Able to report correct month
___ 0 missed by >1 month or no answer
___ 1 Missed by 6 days to one month
___ 2 Accurate within 5 days
Ask resident: "What day of the week is Today?"
Able to report correct day of the week
___ 0 Incorrect, or no answer
___ 1 Correct
Part 3: Ask the following question:
Ask resident: "Let's go back to the earlier question. What were the three words that I asked you to repeat?"
If unable to remember a word, give cue ("something to wear; " "a color; " "a piece of furniture'? for that word.)
Check the blank based on response of resident
___0. No - could ___1. Yes, after cueing ___2. Yes, no cue Able to recall "sock" not recall ("something to wear") required
___0. No - could ___1. Yes, after cueing ___2. Yes, no cue Able to recall "blue" not recall ("a color") required
___0. No - could ___1. Yes, after cueing ___2. Yes, no cue Able to recall "bed" not recall ("a piece of furniture") required
Summary Score
Add scores for each question and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.
TOTAL SCORE
Enter the total score as a two-digit number. The total possible BJMS score ranges from 00 to 15.
13 - 15: cognitively intact
08 - 12: moderately impaired
00 - 07: severe impairment
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Measure 283: Dementia Associated Behavioral & Psychiatric Symptoms
A) Measure 283 Dementia Associated Behavioral & Psychiatric Symptoms _____ N/A patient not known to have a dementia diagnosis at this time. _____ G9920 Patient carrying a Dementia Dx was screened NEGATIVE today for Activity Disturbance, Mood Disturbance, & Thought/Perceptual Disturbance. ______ G99919 Patient carrying Dementia Dx was screened POSITIVE today for Activity Disturbance, Mood Disturbance, &/or Thought/Perceptual Disturbance and Recommendations for patient management provided.
Please review the case while completing your Diagnostic Interview for any evidence of dementia diagnoses previously given in the medical record or observed in the course of your diagnostic interview. Even though we do not bill under a Dementia Dx (as dementia is never the focus of our direct care), many patients carry a previous Dx of Dementia. Our Diagnostic Interview form requires you to screen for activity disturbance, mood disturbance and thought/perceptual disturbance in all patients. It is very likely a patient with dementia referred to our services has some documentable disturbance in activity, mood and thoughts/perceptions in the past 12 months. When performing the 90791, you are being paid to make some helpful recommendations to the care team for patient management based on the specific disturbance. If the patient has no known Dementia Dx, select option “N/A.” If a patient with Dementia is NOT found to have any positive behavioral or psychiatric symptoms in the past 12 months, select G9920 and write “Not Applicable” in the open field requiring your recommendations for patient management. In most cases, a patient with Dementia will be found to have such symptoms in the past 12 months that impact their activity, mood, thoughts/perceptions. In these majority of the cases, select G9919 and then document one or two patient-specific recommendations for management. - Examples of “activity disturbance”: agitation, wandering, eating or sleep problems, repetitive behavior, apathy, hyperactivity, social inappropriateness.
- Examples of “mood disturbance”: depression, anxiety, elation, irritability, lability.
- Examples of “thought/perceptual disturbances”: delusions, hallucinations, paranoia. Please reach out to patient's doctor for clinical support if you are not sure how to make recommendations for patient management.
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Medicare Patients Mental Status Resources
Mental Status Examinations
Manuals
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Measure 134: Screening for Clinical Depression and Follow-Up Plan
D) Measure 134 Depression Screen (e.g.PHQ9, GDS) Scale Used: _______ Score: _________ _____ G8431 positive screen for clinical depression, f/up plan noted as: _________________ _____ G8510 Negative screen for clinical depression, no f/up required. _____ G8433 Screen not performed due to pt refusal, crisis situation, functional capacity limits accuracy of screen
Please utilize the most appropriate depression screen for each and every patient. Some clinicians will prefer to use the PHQ9, while others prefer the Geriatric Depression Scale, Cornell Scale, Beck, etc. Medicare simply requires that we use a "normalized and validated depression screening tool developed for the patient population in which it is being
utilized." The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record, as well as the score. Coping.us provides you with the PHQ9 and the GDS. There are three G codes to choose from. If your depression screen is found to be positive (G8431), then you must also document your follow up plan by selecting one of the options provided in the drop-down box. Examples include a) additional assessment of depression, b) will provide ongoing treatment to reduce/relieve depressive symptoms, c) will complete suicide risk assessment, d) will refer to psychiatry/attending physician for pharmacological interventions. If the screen is negative, select G8510. If patient refuses to complete the screen, is in crisis or has functional capacity limits that would render your screening results inaccurate, you may select G8433 as your finding on this measure. IN 2021 & FORWARD, WE CAN NO LONGER OCUMENT SUICIDE RISK ASSESSMENT AS A FOLLOW UP PLAN TO A POSITIVE DEPRESSION SCREEN.
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Patient Health Questionnaire – 9 (PHQ-9)
1. Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully, and put a check in the box for your response.
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Not
at all
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Several
days
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More than
half the days
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Nearly
every day
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0
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1
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2
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3
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a. Little interest or pleasure in doing things
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b. Feeling down, depressed, or hopeless
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c. Trouble falling asleep, staying asleep, or sleeping too much
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d. Feeling tired or having little energy
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e. Poor appetite or overeating
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f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down
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g. Trouble concentrating on things such as reading the newspaper or watching television
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h. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual
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i. Thinking that you would be better off dead or that you want to hurt yourself in some way
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Totals
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2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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Not Difficult At All
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Somewhat Difficult
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Very Difficult
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Extremely Difficult
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0
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1
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2
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3
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How to Score PHQ-9
Scoring Method for Diagnosis
Major Depressive Syndrome is suggested if:
- Of the 9 items, 5 or more are circled as at least "More than half the days"
- Either item 1a or 1b is positive, that is, at least "More than half the days"
Minor Depressive Syndrome is suggested if:
- Of the 9 items, b, c, or d are circled as at least "More than half the days"
- Either item 1a or 1b is positive, that is, at least "More than half the days"
Scoring Method for Planning and Monitoring Treatment
Question One
To score the first question, tally each response by the number value of each response:
Not at all = 0
Several days = 1
More than half the days = 2
Nearly every day = 3
Add the numbers together to total the score.
Interpret the score by using the guide listed below:
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Score
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Action
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<4
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The score suggests the patient may not need depression treatment.
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> 5-14
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Physician uses clinical judgment about treatment, based on patient’s duration of symptoms and functional impairment.
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>15
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Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment
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Question Two
In question two the patient responses can be one of four: not difficult at all, somewhat difficult, very difficult, extremely difficult. The last two responses suggest that the patient's functionality is impaired. After treatment begins, the functional status is again measured to see if the patient is improving.
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Geriatric Depression Scale (GDS) (Short Form)
1. Are you basically satisfied with your life? YES/NO
2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO
5. Are you in good spirits most of the time? YES/NO
6. Are you afraid that something bad is going to happen to you? YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES/NO
10. Do you feel you have more problems with memory than most? YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are? YES/NO
Responses indicating depression are highlighted. Each highlighted response receives one point; scores greater than 5 are clinically significant. The GDS alone should not be used to diagnose depression.
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Medicare Patients Depression Assessments Resources
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Measure MBHR1: Anxiety Utilization of GAD-7
G) Measure MBHR1 Anxiety Screen Using GAD-7 Score: ______Date Measured: ________
____ PRO2000.4Y Patient was administered GAD-7 ____ N/A Patient not given GAD-7 due to cognitive, visual, motor, reading, or language deficit.
Using the GAD-7 (Generalized Anxiety Disorder tool), measure the current level of anxiety over the past two weeks. Like other quality measures, your clinical judgment and decision making about what you do with the obtained information is important. Payers want us to address any and all symptoms that have the potential to make patients unhealthier both physically and mentally. There is no question that anxiety impacts the quality of life and health status of patients in a negative way. The overall impact of untreated anxiety on the health care system is enormous and is a costly burden to us as taxpayers.
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Generalized Anxiety Disorder (GAD-7) Scale
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Over the last 2 weeks, how often have you been bothered by the following problems?
- Feeling nervous, anxious, or on edge
- Not being able to stop or control worrying
- Worrying too much about different things
- Trouble relaxing
- Being so restless that it's hard to sit still
- Becoming easily annoyed or irritable
- Feeling afraid as if something awful might happen
Add the score for each column
Total Score (add your column scores) =
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Not at
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Several
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Over half
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Nearly
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all sure
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days
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the days
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every day
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0
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1
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2
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3
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0
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1
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2
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3
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0
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1
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2
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3
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0
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1
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2
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3
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0
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1
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2
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3
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0
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1
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2
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3
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0
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1
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2
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3
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+
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+
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If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult ____
Extremely difficult
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Measure 128: Body Mass Index (BMI) Screening and Follow-Up Plan
C) Measure 128 Body Mass Index Score: ______Date Calculated:________Calculated By:________
Normal parameters: BMI > or = 18.5 and <25 _____ G8420 BMI w/in normal parameters, no f/up needed. _____ G8417 BMI above normal, f/up plan noted as: ________________ _____ G8418 BMI below normal, f/up plan noted as: ________________ _____ G2181 No BMI documented due to pt refusal, hospice care, crisis situation, or BMI not appropriate to measure
[Calc Def: English Units: BMI = Weight (lbs) / [(Height (in)] 2 x 703]
You may obtain an official medical report on patient height and weight within the last 12 months from the facility chart, facility staff, or other medical record, but you may not utilize patient "self-report" of height and weight for this measure. Select one of the four G codes. If BMI is out of normal range, then you need to specify a follow up plan. Examples include education, referral to other provider such as dietician, PT/OT, pharmacological services, exercise or nutrition counseling.
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Measure 431: Unhealthy Alcohol Use Screening and Brief Counseling
HOW MANY TIMES IN THE PAST 12 MONTHS DID YOU HAVE MORE THAN 5 (men) or 4 (women) DRINKS IN A DAY? Patient classified as “unhealthy user” if the response is >/= 1 day in past 12 months. _____ G2197 G9622 Patient not identified as an unhealthy alcohol user by systematic screener.
_____ G2196 G9220 G9621 Patient is identified as an unhealthy user and received brief counseling this visit. _____ G2198 G9623 Patient not screened due to limited life expectancy, crisis situation, or other documented medical reason
This measure requires you to simply indicate whether or not you asked the patient the prompt above and if confirmed to be an unhealthy alcohol user, you then provide brief related counseling for minimum of 5 minutes. If male patients state they have had more than 5 drinks in a day at least 1 day in the past 12 months, they are positive for unhealthy alcohol use. Female patients should be asked “How many times in the past 12 months did you have more than 4 drinks in a day?” If they respond with 1 day or greater, they are positive for unhealthy alcohol use. If the patient is NOT identified as an unhealthy alcohol user by this systematic screener, then you select G2197,G9622. If the patient is identified as an UNHEATHLY USER of ALCOHOL, select G2196, G2200, G9621, and in this visit, you should perform 5-15 minutes of counseling in which you either: provide feedback on alcohol use and harms, identify high risk situations for drinking along with coping strategies, and/or increase motivation and develop a personal plan to reduce drinking. If the patient is not screened this visit due to limited life expectancy, crisis situation or some other documented medical reason, then select G2198, G9623.
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The Alcohol Use Disorders Identification Test (AUDIT):
Interview Version
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Read questions as written. Record answers carefully.
Begin the AUDIT by saying
“ Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “ alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “ standard drinks” . Place the correct answer number in the box at the right.
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1. How often do you have a drink containing alco- hol?
(0) Never [Skip to Qs 9-10]
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
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6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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2. How many drinks containing alcohol do you have on a typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
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7. How often during the last year have you had a feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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3. How often do you have six or more drinks on one occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0
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8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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4. How often during the last year have you found that you were not able to stop drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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9. Have you or someone else been injured as a result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
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5. How often during the last year have you failed to do what was normally expected from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
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Record total of specific items here
If total is greater than recommended cut-off, consult User’s Manual.
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Measure 226: Tobacco Use: Screening and Cessation Intervention
E) Measure 226 Tobacco Use Screen & Cessation Intervention ____ G9902 G9906 4004F Patient screened for tobacco use, identified as a user, & received 3-minute cessation counseling. ____ G9903 1036F Pt screen for tobacco use and is currently NOT a tobacco user. ____ G9904 4004F with 1P No tobacco use screen performed or f/up due to limited life expectancy or other medical reason
This measure is simple to report! It refers to any use of tobacco, but does not include nicotine patches or other addictive substances. This measure requires you to simply indicate whether or not you asked if the patient is a tobacco user and if patient is currently a user of tobacco in any form, then you select G9902/G9906/4004F and perform a three minute
"cessation counseling intervention" and/or recommend pharmacotherapy. The other two options include "patient screened and is not a tobacco user" (G9903/1036F) and "patient was not screened due to medical reason or limited life expectancy" (G9904/4004Fwith1P).
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Measure 181: Elder Maltreatment Screen and
Follow-Up Plan
(for patients 65 and older only)
F) For ages 65+: Measure 181 Elder Maltreatment Screen (Elder Abuse Suspicion Index)
____ G8733 Positive screen, f/up plan noted as: ________________________________
_____ G8734 Negative screen, no f/up required.
_____ G8535 Elder maltreatment screen not performed due to pt was in crisis situation during session or patient refusal to participate in screen & has decisional capacity for self-protection.
Using the EASI (Elder Abuse Suspicion Index) tool, please obtain yes, no, or cannot say responses on the
6 items. Like many of the other quality measures, your keen clinical judgment and decision making about
what you do with the obtained information will be important. This measure has a strong potential for
many false positives in the SNF and AL setting. In our unique treatment setting, it will be very common to
have "yes" responses from many of our patients that in actuality do not constitute serious threats to the
patient (e.g., many patients do rely on others for bathing or banking and many are often upset by the
facility not getting the food they want, pain meds upon demand, etc.). Medicare simply wants us to be
aware of the risk factors for elder maltreatment and to have a watchful eye as a healthcare provider.
Like many of the tools used in PQRS data gathering, you do not report the specific findings from the
EASI scale. You simply report one of the three available G codes. If you have a truly positive elder
abuse situation (G8733), you must document the specific follow up plan (which 100% of the time means
you will be notifying the facility staff who will be required to make a report to APS and other state
authorities). If you have a negative screen, select G8734. If the patient is in emerging crisis during
session or refuses to respond to the measure and has decisional capacity to self-protect, then you
select G8535.
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ELDER ABUSE SUSPICION INDEX (EASI)
EASI Questions
Q.1-Q.5 asked of patient; Q.6 answered by doctor Within the last 12 months:
1) Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
YES NO Did not answer
2) Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with?
YES NO Did not answer
3) Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
YES NO Did not answer
4) Has anyone tried to force you to sign papers or to use your money against your will?
YES NO Did not answer
5) Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
YES NO Did not answer
6) Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?
YES NO Not sure
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Additional Assessments for Patients in Residential Settings or at Home
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The Suicide Behaviors Questionnaire-Revised (SBQ-R)
Instructions: Please check the number beside the statement or phrase that best applies to you.
1. Have you ever thought about or attempted to kill yourself? (Check one only)
1. Never
2. It was just a brief passing thought
3a. I have had a plan at least once to kill myself but did not try to do it
3b. I have had a plan at least once to kill myself and really wanted to die
4a. I have attempted to kill myself‚ but did not want to die
4b. I have attempted to kill myself‚ and really hoped to die
2. How often have you thought about killing yourself in the past year? (Check one only)
1. Never
2. Rarely (1 time)
3. Sometimes (2 times)
4. Often (3-4 times)
5. Very Often (5 or more times)
3. Have you ever told someone that you were going to commit suicide‚ or that you might do it?
(check one only)
1. No
2a Yes‚ at one time‚ but did not really want to die
2b Yes‚ at one time‚ and really wanted to die
3a Yes‚ more than once‚ but did not want to do it
3b Yes‚ more than once‚ and really wanted to do it
4. How likely is it that you will attempt suicide someday? (check one only)
0. Never
1. No chance at all
2. Rather unlikely
3. Unlikely
4. Likely
5. Rather likely
6. Very likely
The SBQ-R has 4 items‚ each tapping a different dimension of suicidality
Item 1 taps into lifetime suicide ideation and/or suicide attempt.
Item 2 assesses the frequency of suicidal ideation over the past twelve months.
Item 3 assesses the threat of Suicide attempt.
Item 4 evaluates self-reported likelihood of suicidal behavior in the future.
Clinical Utility
Due to the wording of the four SBQ-R items‚ a broad range of information is obtained in a very brief administration. Responses can be used to identify at-risk Individuals and specific behaviors.
Psychometric Properties’ Cutoff score Sensitivity Specificity
Adult General Population >=7 93% 95%
Adult Psychiatric Inpatients >=8 80% 91%
SBQ-R – Scoring
Item 1:taps into lifetime suicide ideation and/or suicide attempts
selected response 1 Non Suicidal subgroup 1 point
selected response 2 Suicide Risk Ideation subgroup 2 point
selected response 3a or 3b Suicide Plan subgroup 3 point
selected response 4a or 4b Suicide Attempt subgroup 4 point Total Points
Item 2: assesses the frequency of suicidal ideation over the past 12 months’
selected response
Never 1 point
Rarely (1 time) 2 point
Sometimes (2 times) 3 point
Often (3-4 times) 4 point
Very Often (5 or more times) 5 point Total Points
Item 3: taps into the threat of suicide attempt
selected response 1 1 point
selected response 2a or 2b 2 point
selected response 3a or 3b 3 point Total Points
Item 4: evaluates self-reported likelihood of suicidal behavior in the future
selected response Never 0 point
No chance at all 1 point
Rather unlikely 2 point
Unlikely 3 point
Likely 4 point
Rather Likely 5 point
Very Likely 6 point Total Points
Sum all the scores circled/checked by the respondents.
The total score should range from 3-18. Total Score = ___________
AUC = Area Under the Receiver Operating characteristic Curve; the area measures discrimination. that is‚ the ability of the test to correctly classify those with and without the risk. [.90-1.0 = Excellent; .80-.90 = Good; .70-.80 = Fair; .60-.70= Poor]
Sensitivity Specificity PPV
Item 1: a cutoff score of >= 2
• Validation Reference: Adult Inpatient 0.8 0.97 .95
Total SBQ-R: a cutoff score of >=7
Total SBQ-R: a cutoff score of >= 8
• Validation Reference: Adult Inpatient 0.80 0.91 0.87
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Risk for Suicide Assessment
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Client Concerns
From time to time during the course of your treatment, we may ask you to fill out this form; it will help us work together with you to monitor your progress.
Name: ____________________ Date: ___________________
For each item on this list, please use the 0-to-3 rating to indicate how much it has concerned you during the past month. Draw a circle around the most appropriate number, using these definitions:
0 = Not at all 1 = A little concern 2 = More than a little 3 = A lot of concern
Aggression, violence 0 1 2 3
Alcohol use 0 1 2 3
Anger, hostility, arguing, irritability 0 1 2 3
Anxiety, nervousness, worry 0 1 2 3
Attention, distractibility, can’t concentrate 0 1 2 3
Career concerns, goals, and choices 0 1 2 3
Childhood issues (your own childhood) 0 1 2 3
Children, child management, child care, parenting/guardianship 0 1 2 3
Codependent, dysfunctional relationships 0 1 2 3
Conflicts with others 0 1 2 3
Confusion, disorganized thoughts 0 1 2 3
Decision making, indecision, mixed feelings, putting off decisions 0 1 2 3
Delusions (false ideas) 0 1 2 3
Dependence 0 1 2 3
Depression, low mood, sadness, crying 0 1 2 3
Divorce, separation, child custody 0 1 2 3
Drug use: prescription medications, over the-counter medications, street drugs 0 1 2 3 Eating problems – overeating, undereating, appetite issues, vomiting 0 1 2 3
Failure 0 1 2 3
Fatigue, tiredness, low energy 0 1 2 3
Fears, phobias 0 1 2 3
Financial or money troubles, debt, impulsive spending, low income 0 1 2 3
Friendships, lack of social support 0 1 2 3
Gambling 0 1 2 3
Grieving, death, other losses 0 1 2 3
Guilt, feeling guilty 0 1 2 3
Health, illness, medical concerns, physical problems, pain, nausea 0 1 2 3
Hopelessness 0 1 2 3
Inferiority feelings, lack of confidence 0 1 2 3
Impulsiveness, loss of control, outbursts 0 1 2 3
Irresponsibility, judgment problems, taking unnecessary risks 0 1 2 3
Jealousy, feeling jealous 0 1 2 3
Legal matters, charges, lawsuits 0 1 2 3
Loneliness, emptiness 0 1 2 3
Marital conflict, distance/coldness, infidelity/affairs, remarriage 0 1 2 3
Memory problems 0 1 2 3
Menstrual problems, PMS, menopause 0 1 2 3
Mood swings 0 1 2 3
Motivation, feeling lazy, lack of interest 0 1 2 3
Nervousness, restlessness, fidgeting 0 1 2 3
Obsessions and/or compulsions (thoughts or actions that repeat themselves) 0 1 2 3 Oversensitivity to rejection or criticism 0 1 2 3
Panic or anxiety attacks 0 1 2 3
Perfectionism 0 1 2 3
Pessimism 0 1 2 3
Relationship problems 0 1 2 3
School problems 0 1 2 3
Self-cutting, self-mutilation 0 1 2 3
Self-neglect, difficulty with self-care 0 1 2 3
Sexual issues, sexual orientation, gender identity issues 0 1 2 3
Shyness 0 1 2 3
Sleep problems – too much, too little, insomnia, nightmares 0 1 2 3
Stress, stress management, stress disorders, tension 0 1 2 3
Suicidal thoughts 0 1 2 3
Suspiciousness, problems trusting people 0 1 2 3
Temper problems, self-control, low frustration tolerance 0 1 2 3
Thoughts of death or dying 0 1 2 3
Threats, fear of being harmed 0 1 2 3
Traumatic memories, re-living trauma 0 1 2 3
Urges to beat, injure, or harm someone 0 1 2 3
Urges to break or smash things 0 1 2 3
Weight and diet issues 0 1 2 3
Withdrawal, self-isolation 0 1 2 3
Work problems, employment, trouble keeping a job, workaholic/overworking 0 1 2 3 Other concerns ______________: 0 1 2 3
Other concerns ______________: 0 1 2 3
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Client's Progress Survey
Name:________________ Date: _____________________________
Part 1: We are interested in the goals you have for therapy. For each potential goal on the list, please circle Yes or No to indicate whether this is one of your goals, and if it is, whether or not you are making progress toward this goal.
Therapy Goals
Is this one of your goals? Are you making progress toward this goal?
1. Improve relationships Yes No Yes No N/A
2. Increase self-esteem Yes No Yes No N/A
3. Decrease depression Yes No Yes No N/A
4. Improve school/work functioning Yes No Yes No N/A
5. Cope with anger/frustration Yes No Yes No N/A
6. Decrease stress/anxiety Yes No Yes No N/A
7. Improve family functioning Yes No Yes No N/A
8. Increase satisfaction in friendships Yes No Yes No N/A
9. Take better care of myself Yes No Yes No N/A
10. Change addictive behavior Alcohol
Eating Disorder Other: Yes No Yes No N/A
11. Reduce self-destructive behavior Yes No Yes No N/A
12. Other: Yes No Yes No N/A
What are the concerns or goals that you most want help with?
Part 2: Please answer these questions about any current alcohol or drug use.
1. Have you ever felt you should cut down your drinking or drug use? Yes No
2. Have people annoyed you by criticizing your drinking or drug use? Yes No
3. Have you ever felt bad or guilty about your drinking or drug use? Yes No
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? Yes No
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REQUEST FOR EXAMINATION OF DRIVER
INCIDENT INFORMATION
Date and time of incident __________ Location of incident _____________
Was an accident involved? YES NO
Was the driver given a citation? YES NO
Check one or more of the following that apply and describe
in the summary section below:
General physical/health problem
Diabetic loss of consciousness or voluntary control
Vision problem
Lack of physical driving skills
Mental or emotional problem (including road rage, memory loss, etc.)
Loss of consciousness or voluntary control (seizures)
Lack of knowledge of traffic laws
Other
Violation of "ANY USE OF ALCOHOL/DRUG INVALIDATES LICENSE" restriction (please attach report verifying alcohol/drug use)
SUMMARY - Describe in detail the driving actions or conditions that brought this driver to your attention. Why do you feel this driver should be re-examined? Please attach any pertinent reports that would be helpful to the driver evaluator.
Age alone cannot be considered good cause for re-examination.
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Additional Information on Assessments for Aging Senior Patients in Residential Settings or at Home
Measuring Psychosocial Treatment Outcomes with Older People at:
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