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Online Pastor/Church Leader Assessment Form

Lighthouse Network > Online Pastor/Church Leader Assessment Form

Online Pastors Assessment Form

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Basic Demographics
Method of Client Assessment
- In Person
- Telephonic
Client Assessment done with:
- Client directly
- Loved one
Pastor's Name*
Pastor's Email*
Pastor's Phone*
Date
MM slash DD slash YYYY
Client First Name
Client Last Name
Client Address
Street Address Address Line 2 City Your State ZIP Code
Client Home Phone
Client Cell Phone
Client Email
Client Age
Please enter a number from 1 to 99.
Client Date of Birth
MM slash DD slash YYYY
Religion
Interested in Christian Programming
- Yes
- No
Agreeable to Treatment
- Yes
- No
Agreeable to Residential Treatment
- Yes
- No

Mental Health Clinical Information
Sleep
- Not Enough
- Too Much
- Normal
Appetite
- Not Enough
- Too Much
- Normal
Energy
- Not Enough
- Too Much
- Normal
Impared Concentration
- Yes
- No
No Enjoyment of Life's Activities
- Yes
- No
Guilty Feelings
- Yes
- No
Hopeless Feelings
- Yes
- No
Helpless Feelings
- Yes
- No
Agitation
- Yes
- No
Thoughts of Death
- Yes
- No
Suicidal Thoughts
- Yes
- No
Suicide Intent
- Yes
- No
Suicide Plan
- Yes
- No
Past Suicide Attempts
- Yes
- No
Obsessions
- Yes
- No
Compulsions
- Yes
- No
Panic Attacks
- Yes
- No
Nightmares
- Yes
- No
Flashbacks
- Yes
- No
Avoidance or Phobias
- Yes
- No
Memory Issues
- Yes
- No
Dissociative Episodes
- Yes
- No
Impulsive
- Yes
- No
Temper Problems
- Yes
- No
Aggressive Behavior
- Yes
- No
Crying Spells
- Yes
- No
Decision Making Struggles
- Yes
- No
Confidence Issues
- Yes
- No
Social Anxiety
- Yes
- No
Communication Struggles
- Yes
- No
Past Abortion or Miscarriage
- Yes
- No
Significant Loss in the Last 1 Year
- Yes
- No
Significant Loss in the Last 5 Years
- Yes
- No
Depression Severity
- None
- 1
- 2
- 3
- 4
- 5
- Incapacitated
Anxiety Severity
- None
- 1
- 2
- 3
- 4
- 5
- Incapacitated
Psychoses Severity
- None
- 1
- 2
- 3
- 4
- 5
- Incapacitated
Eating Disorder Severity
- None
- 1
- 2
- 3
- 4
- 5
- Incapacitated
GAF Score
Please enter a number from 0 to 100.
https://www.msu.edu/course/sw/840/stocks/pack/axisv.pdf
Currently on any Psychiatric Medications
- Yes
- No
List Medications
Past History of Abuse
- Yes
- No
If Yes (check all that apply)
- Sexual
- Physical
- Emotional
- Psychological
Have You Ever Had Any Past Psychiatric Treatment?
- Yes
- No
If Yes, WHat Level of Care?
- Inpatient
- Long-Term Residential
- PHP
- IOP
- Outpatient

Addiction Clinical Information
Addiction Severity
- None
- 1
- 2
- 3
- 4
- 5
- Incapacitated
Alcohol
- Yes
- No
Frequency Of Use (Alcohol)
History of Alcohol Withdrawl
- Yes
- No
Alcohol Withdrawl Seizures
- Yes
- No
Marijuana Use
- Yes
- No
Frequency Of Use (Marijuana)
Marijuana History of Withdrawl
- Yes
- No
Prescription Drug Use
- Yes
- No
Frequency Of Use (Prescription Drugs)
If Yes (check all that apply)
- Pain Med / Opioid
- Tranquilizer / Benzo
- Stimulant
- Sleeping Pills
Do you take as prescribed?
- Yes
- No
History of Prescription Drug Withdrawl
- Yes
- No
Illegal Drug Use
- Yes
- No
Frequency Of Use (Illegal Drug Use)
Illegal Drug Use Withdrawl?
- Yes
- No
Heroin / Opioid Use?
- Yes
- No
Frequency Of Use (Heroin/Opioid Use)
History of Heroin / Opioid Withdrawl?
- Yes
- No
Stimulant Use
- Yes
- No
Frequency Of Use (Stimulant)
History of Stimulant Use Withdrawl?
- Yes
- No
Hallucinogen Use
- Yes
- No
Frequency Of Use (Hallucinogen)
History of Hallucinogen Use Withdrawl?
- Yes
- No
Party Drug Use
- Yes
- No
Frequency Of Use (Party Drug)*
History of Party Drug Use Withdrawl?
- Yes
- No
Process Adiction
- Yes
- No
Process Addiction Type
Other Process Addiction Type
Past Addiction Treatment
- Yes
- No
Past Addiction Treatment
- Detox
- Acute Residential
- Sleepover PHP
- PHP
- IOP
- Outpatient
- Long Term Residential (more than 60 days)
- Recovery Support Group
Adverse Legal Impact
- Yes
- No
Adverse Relational / Marital Impact
- Yes
- No
Adverse Financial Impact
- Yes
- No
Adverse Living Situation / Housing Impact
- Yes
- No
Adverse Work Vocational Impact
- Yes
- No
Taking the substance in larger amounts or for longer than you meant to
- Yes
- No
Wanting to cut down or stop using the substance but not managing to
- Yes
- No
Spending a lot of time getting, using, or recovering from use of the substance
- Yes
- No
Cravings and urges to use the substance
- Yes
- No
Not managing to do what you should at work, home or school because of substance use
- Yes
- No
Continuing to use even when it causes problems in your life
- Yes
- No
Giving up important social, occupational or recreational activities because of substance use
- Yes
- No
Using substances again and again, even when it puts you in danger
- Yes
- No
Continuing to use, even when you know you have a physical or phychological problem that could have been caused or made worse by the substance
- Yes
- No
Needing more of the substance the get the effect you want (tolerance)
- Yes
- No
Development of withdrawl symptoms, which can be relieved by taking more of the substance
- Yes
- No
Social History
Living
Working
Education
Financial Stress
Sexual Perpetrator
- Yes
- No
Registered Sex Offender
- Yes
- No
History of Fire Setting
- Yes
- No

Medical History
Medical Issues Causing Stress
Are your medical conditions worsened by your mental illness?
- Yes
- No
Are your medical conditions worsened by your substance abuse or process addiction?
- Yes
- No
Are you pregnant?
- Yes
- No
Are you able to walk without assistance?
- Yes
- No
Are you able to walk without human assistance?
- Yes
- No
Do you have any visual impairment?
- Yes
- No
Do you have any hearing impairment?
- Yes
- No
Are you able to physically take care of your dressing, toileting, eating?
- Yes
- No
Are you currently taking any prescription medications?
- Yes
- No
List and explain medication taken

Current Mental Status
Appearance
Oriented To
Level of Consciousness
Speech
Affect
Mood
Thought Processes
Thought Content
Cognitive / Memory
Recall
Concentration
Attention
Intelligence
Judgement
Insight

Diagnosis or Assessment
Mental Health Diagnosis
Mood Disorder
Anxiety Disorder
Psychotic Disorder
Eating Disorder
Developmential Disorders
Dementia
- Yes
- No
Adjustment Disorder
- Yes
- No
Recommendations (select all that apply)
- Acute Inpatient
- Longer Term Residential
- PHP / Day Treatment Program
- IOP
- Outpatient
- Group
- Family
- Individual
- Psychiatry Mediation Evaluation
Addiction Diagnosis
Drug
- Alcohol
- Marijuana
- Stimulants
- Opioids
- Hallucinogens
- Tranquillizers
- Inhalant
- Unknown Drug
- Process
Recommendations (select all that apply)
- Acute Residential Addiction Treatment (less than 60 days)
- Addiction Detox
- Long Term Addiction Treatment (more than 60 days)
- Halfway House
- Outpatient Addiction Treatment
- PHP
- IOP
- Outpatient
- Family
- Recovery Group

Insurance Information
Insurance Company Name
Insurance Company Benefits Phone #
Group #
Client ID#
Client Date of Birth
MM slash DD slash YYYY
Client SSN
Insurance Primary Name (If different)
Primary Date of Birth
Primary SSN
Address of Primary
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Medicare
- Yes
- No
If yes, Medicare # on the Card
Cash Funds for Treatment (Personal, Family, Friends, Church)
- Yes
- No
Amount of funds that are available.
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