Mental Health Assessment Form

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Mental Health Assessment Form 
Unaccompanied Alien Children Bureau
Office of Refugee Resettlement (ORR)
General Information
Child

Last name:
First name:


DOB:  
A#:
Sex:
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: _________________________________________________________________







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 09/30/2026. If you have any comments on this collection of information, please contact [email protected].