535 Ocean Avenue, Suite 4, Portland, ME 04103

Phone: (207) 370-5389  |  Fax: (207) 510-8054  |  Email: info@catt-associates.com

Assessment

You may work on the Assessment and "Save and Submit Later" by clicking on the "button" below. 

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  2. Copy Link
  3. Compose email to your CATT Email
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  6. You can repeat these steps as many times as you need.
  7. Click "Submit" when 100% Complete
Client Legal Name:*
Client Preferred Name (If Different Than Client Legal Name):
Intake Date: *
Outpatient - First Session with Client / HCT - Date Referral Was Received (Check With Admin Team)
Do not leave as "Unsure / Not Listed." Thank you.
Type of Assessment (Must Be Completed Annually)*
Date of Initial Assessment: *
Please use date as shown on Treatment Plan Tracker
Should be 30 Days or Less
Date of First Annual Assessment*
365 Days from Initial Assessment
Should be 365 Days or Less
Date of Second Annual Assessment*
730 Days from Initial Assessment
Should be 365 Days or Less
Date of Third Annual Assessment*
1,095 Days from Initial Assessment
Should be 365 Days or Less
Date of Fourth Annual Assessment*
1,460 Days from Initial Assessment
Should be 365 Days or Less
Date of Fifth Annual Assessment*
1,825 Days from Initial Assessment
Should be 365 Days or Less
Date of Sixth Annual Assessment*
2,190 Days from Initial Assessment
Should be 365 Days or Less
Date of Expiration: *
365 Days from Date of Assessment (Next Annual Assessment Due on this Date)

Reason for Treatment

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Including hobbies, spiritual beliefs, support systems, etc.

History of Developmental/Family/Social

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Including education level, education services, adverse circumstances, etc.
Including employment history, disability benefits, etc.
Including social, leisure, and recreational interests, etc.
Including current and past medical issues.
Including prescription and over-the-counter.

History of Mental Health Treatment

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Prior Mental Health Treatment?*
(Please only check one)
Including type of treatment, level of care, provider(s), location(s), etc.
Past Suicidal Ideation?*
(Please only check one)
Past Suicidal Attempts?*
(Please only check one)
Past Inpatient Admissions?*
(Please only check one)
Family History of Mental Illness?*
(Please only check one)

History of Abuse

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Client has been exposed to neglect as a:*
Please check all that apply.
Including nature of relationship(s), duration and severity of abuse, etc.
Client has been exposed to physical abuse as a:*
Please check all that apply.
Including nature of relationship(s), duration and severity of abuse, etc.
Client has been exposed to emotional abuse as a:*
Please check all that apply.
Including nature of relationship(s), duration and severity of abuse, etc.
Client has been exposed to sexual abuse as a:*
Please check all that apply.
Including nature of relationship(s), duration and severity of abuse, etc.
Type "N/A" if not applicable.

Current Risk Assessment

Is the client currently suicidal?*
(Please only check one)
Is the client currently homicidal?*
Does the client own or have access to firearms or other weapons?*
How at risk does the client feel now?*
Clinical Assessment for Client's Risk of Needing Crisis Intervention Services:*
*If medium or high, please attach a crisis/safety plan.

Substance Use History

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Substance(s) Used:
Please check all that apply.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
MM/DD/YY, if possible. If not, please provide as many details as possible.
Substance(s) Impacting Client's Life To Assess Further:
Please check all that apply.
Write "N/A" if not applicable.
Alcohol Age of Onset:
(Please only check one)
Duration of Alcohol Use:
(Please only check one)
Pattern of Alcohol Use:
Please check all that apply.
Tolerance of Alcohol:
(Please only check one)
Write "N/A" if not applicable.
Cannabis Age of Onset:
(Please only check one)
Duration of Cannabis Use:
(Please only check one)
Pattern of Cannabis Use:
Please check all that apply.
Tolerance of Cannabis:
(Please only check one)
Write "N/A" if not applicable.
Opiates Age of Onset:
(Please only check one)
Duration of Opiate Use:
(Please only check one)
Pattern of Opiates Use:
Please check all that apply.
Tolerance of Opiates:
(Please only check one)
Write "N/A" if not applicable.
Cocaine Age of Onset:
(Please only check one)
Duration of Cocaine Use:
(Please only check one)
Pattern of Cocaine Use:
Please check all that apply.
Tolerance of Cocaine:
(Please only check one)
Write "N/A" if not applicable.
Hallucinogen Age of Onset:
(Please only check one)
Duration of Hallucinogen Use:
(Please only check one)
Pattern of Hallucinogen Use:
Please check all that apply.
Tolerance of Hallucinogen:
(Please only check one)
Write "N/A" if not applicable.
Inhalant Age of Onset:
(Please only check one)
Duration of Inhalant Use:
(Please only check one)
Pattern of Inhalant Use:
Please check all that apply.
Tolerance of Inhalants:
(Please only check one)
Write "N/A" if not applicable.
Uppers Age of Onset:
(Please only check one)
Duration of Uppers Use:
(Please only check one)
Pattern of Uppers Use:
Please check all that apply.
Tolerance of Uppers:
(Please only check one)
Write "N/A" if not applicable.
Sedatives Age of Onset:
(Please only check one)
Duration of Sedatives Use:
(Please only check one)
Pattern of Sedatives Use:
Please check all that apply.
Tolerance of Sedatives:
(Please only check one)
Write "N/A" if not applicable.
Caffeine Age of Onset:
(Please only check one)
Duration of Caffeine Use:
(Please only check one)
Pattern of Caffeine Use:
Please check all that apply.
Tolerance of Caffeine:
(Please only check one)
Write "N/A" if not applicable.
Nicotine Age of Onset:
(Please only check one)
Duration of Nicotine Use:
(Please only check one)
Pattern of Nicotine Use:
Please check all that apply.
Tolerance of Nicotine:
(Please only check one)
Write "N/A" if not applicable.
"Other Substance" Age of Onset:
(Please only check one)
Duration of "Other Substance" Use:
(Please only check one)
Pattern of "Other Substance" Use:
Please check all that apply.
Tolerance of "Other Substance":
(Please only check one)
Criteria for Substance Use Disorder
Total Number Boxes Checked: _________________ Severity: Mild: 2-3 symptoms. Moderate: 4-5 symptoms. Severe: 6 or more symptoms
Biological Family History of Drug Use:
Please check all that apply.
Consequences of Substance Use:
Please check all that apply.

Mental Health Status Exam

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Appearance:*
Please check all that apply.
Manner:*
Please check all that apply.
Attention:*
Please check all that apply.
Speech Rate: *
Please check all that apply.
Speech Volume: *
Please check all that apply.
Mood:*
Please check all that apply.
Affect:*
Please check all that apply.
Thought Processes | Content:*
Please check all that apply.
Thought Processes | Associations: *
Please check all that apply.
Thought Processes | Psychological Signs:*
Please check all that apply.
Cognitive Functions | Intellectual Level:*
Please check all that apply.
Cognitive Functions | Memory:*
Please check all that apply.
Cognitive Functions | Judgement: *
Please check all that apply.
Cognitive Functions | Insight:*
Please check all that apply.
Cognitive Functions | Oriented To:*
Please check all that apply.
Specific Barriers to Treatment: *
Please check all that apply.
Including DSM-5 code, DSM-5 description, and specifier(s) as appropriate.
Treatment Recommendations:*
Please check all that apply.
Use your mouse or finger to draw your signature above
Please ensure the correct credentials are selected prior to submission.
Date of Signature:*
: :  
Use your mouse or finger to draw your signature above
Date of Signature:*

You may work on the Assessment and "Save and Submit Later" by clicking on the "button" below. 

When doing this, it's best to: 

  1. Click "Save and Submit Later"
  2. Copy Link
  3. Compose email to your CATT Email
  4. Paste Link
  5. In Subject Line of Email: List client initials, date & form for your own reference
  6. You can repeat these steps as many times as you need.
  7. Click "Submit" when 100% Complete
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