Initial Clinical Assessment Adult Template - Contra Costa 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the client's name and MRN at the top of the form. This is essential for identification.
3. Fill in the billing information, including program name and staff number. Specify hours worked if applicable.
4. Indicate whether the client is pregnant and select the location of services from the provided options.
5. Complete the 'Service Strategies' section by checking up to three applicable strategies that will be utilized.
6. Provide detailed client information, including legal name, age, date of birth, preferred name, gender, marital status, and address.
7. Document any relevant family/social history and presenting problems that led to this assessment.
8. Assess treatment history by checking appropriate boxes and providing comments where necessary.
9. Complete risk assessments regarding danger to self or others, as well as any additional risk factors present.
10. Finalize with medical history details, criminal justice history if applicable, substance use information, and an initial treatment plan.

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