Long-Term Care Behavioral Health Initial Assessment (SNF/ALF)

Date/Time of Service: [Date and time of encounter]

Facility/Unit/Room: [Facility name / Unit / Room]

Clinician: [Name, credentials]

Resident: [Resident full name]

DOB: [Date of birth]

Referral Source: [Name and role/title]

Reason for Referral: [One-line summary of behavioral concern prompting consultation]

Referral Question & Consultation Framing

[Stated referral question(s) from referring party] (If unclear, state how it was clarified or that clarification is pending.)

• Primary behavioral concern(s): [Behaviors creating risk, distress, or care barriers]
• Time course/onset: [Onset, recent changes, precipitating events such as relocation, roommate change, infection, medication change, loss]
• Urgent safety concerns: [Recent aggression, self-harm statements, elopement attempts, severe care refusal / none reported] (Use direct quotes for high-stakes statements when available.)
• Constraints/considerations: [Sensory impairment, aphasia, suspected delirium, interpreter needs, cultural/linguistic factors / none identified]

Sources of Information & Reliability

• Resident interview: [completed / attempted / declined] [Setting and duration]
• Collateral interviews: [Names and roles of informants interviewed]
• Chart review: [Items reviewed: diagnoses, recent hospitalizations, MAR, labs/vitals, MDS/care plan, incident reports]
• Direct observation: [Dates, times, settings, and activities observed]
• Reliability statement: [Assessment of history reliability given cognitive or communication status]
• Missing data and plan: [Key unavailable sources and plan to obtain] (Omit if all relevant sources obtained.)

Consent & Capacity to Participate

[Documentation that assessment purpose and confidentiality limits in facility setting were explained]

• Consent status: [consented / assented / declined] (If representative involved, note name, relationship, and authority.)
• Capacity to participate: [Ability to understand questions, express preferences, engage in interview]
• Accommodations: [Hearing amplification, visual aids, interpreter, simplified language, shortened interview, breaks / none needed]

(If resident refused assessment, document what was offered, resident's stated reason in quotes, safety check completed, and reattempt plan.)

Presenting Problem Narrative

[Narrative summary of chief behavioral concern including: baseline mood/behavior/function; what has changed and when; frequency/timing/contexts of concerning behaviors; impact on resident safety, care delivery, and staff; identified precipitants or maintaining factors; prior strategies attempted with results] (If resident cannot participate and collateral/chart data are limited, provide summary from available sources and explicitly note limitations.)

Target Behaviors: Operational Definitions

(Repeat the following structure for each target behavior identified. Use neutral, observable terms.)

• Behavior name: [Neutral label, e.g., physical resistance during ADL care / exit-seeking / verbal outbursts]
• Operational definition: [Observable actions in specific, measurable terms]
• Contexts/situations: [Settings, activities, people, times when behavior occurs]
• Frequency/duration/intensity: [Best estimate] (Note confidence level: low/medium/high.)
• Risk severity: [Injury risk, neglect risk, elopement risk, falls risk / minimal risk]
• Current management strategies: [What staff currently do, including PRN usage patterns]
• Baseline measurement plan: [What will be tracked, method, start date, responsible staff] (If baseline frequency unknown, specify tracking method to initiate.)

Behavioral Formulation

(Organize by target behavior if multiple. Clearly label hypotheses as such unless supported by repeated consistent patterns.)

• Antecedents (A): [Immediate triggers; environmental conditions; communication triggers; internal/physiologic antecedents; trauma-related cues]
• Behavior description (B): [Topography; early warning signs/prodrome; escalation sequence; post-episode recovery pattern]
• Consequences (C): [Typical staff responses; resident outcomes; patterns of unintended reinforcement]
• Setting events: [Vulnerability factors such as poor sleep, recent illness, delirium indicators, medication changes, pain flares, loss/grief, relocation stress]
• Hypothesized function(s): [escape/avoidance / access to tangibles / attention/social contact / sensory or comfort regulation] [Supporting observations for each hypothesis]

Cognitive & Communication Status

• Alertness/arousal: [Level and any fluctuations]
• Orientation: [person / place / time / situation]
• Attention: [Sustained/selective attention; distractibility]
• Memory: [Short-term/working memory relevant to plan adherence]
• Language/communication: [Aphasia, word-finding, comprehension level, speech clarity]
• Sensory barriers: [Hearing and vision status; availability and use of aids]
• Capacity for plan cues: [Able to follow one-step prompts / requires visual cue cards / requires modeling]
• Screening results: [BIMS or other cognitive screen scores and dates] (If deferred, state reason and plan to obtain.)

Relevant Psychiatric Symptoms

(Document only applicable domains. Use resident quotes for high-stakes statements. Mark domains not assessed as "not assessed.")

• Mood/anxiety: [Depression, anhedonia, anxiety, irritability, emotional lability / not assessed]
• Psychosis: [Hallucinations, delusions, paranoia; note if command content present / not assessed]
• Sleep: [Sleep disturbance patterns / not assessed]
• Trauma-related: [Re-experiencing, hyperarousal, avoidance, trauma cues / not assessed]
• Substance/nicotine: [Current or recent use; withdrawal risk; nicotine dependence / not assessed]

Medical & Medication Contributors

(Document observations for medical follow-up. Do not state independent medical conclusions.)

• Delirium indicators: [Acute onset, fluctuating attention, altered consciousness / none observed]
• Pain/discomfort: [Observed or chart-noted pain contributors; pain assessment results]
• Medication factors: [Anticholinergic burden; benzodiazepines; opioids; steroids; antipsychotic akathisia risk; recent dose changes; PRN patterns]
• Sensory/equipment: [Missing or ill-fitting glasses, hearing aids, dentures contributing to distress]
• Recommendations for medical follow-up: [Observations warranting medical evaluation]

Relevant History

• Psychiatric/behavioral history: [Prior diagnoses; hospitalizations; prior psychotherapy; history of aggression or self-harm; prior suicide attempts; pertinent trauma history]
• Effective strategies/preferences: [Previously helpful coping strategies; preferences; known reinforcers]
• Social supports: [Family/primary contact; relationship quality; cultural/spiritual preferences]
• Identity/roles & meaningful activities: [Former roles, interests; dignity/engagement factors]
• Strengths: [Humor, responsiveness to music, valued independence, preferred staff approaches]
• Liabilities/triggers: [Known trauma triggers, low frustration tolerance, cognitive rigidity]

(If key history unavailable, state what is missing and plan to obtain collateral.)

Mental Status Examination

• Appearance: [Grooming, dress, hygiene]
• Behavior/psychomotor: [Agitation, retardation, restlessness, abnormal movements]
• Eye contact: [Quality and appropriateness]
• Speech: [Rate, volume, fluency]
• Mood (reported): [Resident's words]
• Affect (observed): [Range, congruence, stability]
• Thought process: [Coherence, organization, tangentiality]
• Thought content: [Delusions, suicidal ideation, homicidal ideation, obsessions]
• Perception: [Hallucinations, illusions / denied / not assessed]
• Cognition: [Attention, orientation as observed]
• Insight/judgment: [Brief assessment]
• Impulse control: [within normal limits / impaired]

(If exam limited, document reason: somnolence, aphasia, refusal, other.)

Risk Assessment & Safety Plan

• Suicide/self-harm risk: [Ideation, intent, plan, means, past attempts, protective factors] (Document key negatives if low risk.)
• Violence/aggression risk: [Identified targets, triggers, staff injury history, access to potential weapons]
• Elopement/exit-seeking risk: [Behaviors, opportunities, current safeguards]
• Vulnerability: [Risk for abuse/neglect/exploitation] (Include if relevant.)
• Capacity/supervision: [Level required for safety]
• Actions taken today: [Notifications made; precautions initiated; reassessment timeline] (Required if risk elevated.)

Diagnostic Impression & Formulation

• Working diagnoses (DSM/ICD): [Primary and secondary diagnoses] (Mark provisional diagnoses as such.)
• Differential considerations: [e.g., delirium vs dementia-related behaviors vs primary psychiatric disorder]
• Biopsychosocial formulation: [Integration of medical contributors, cognitive status, environmental factors, reinforcement patterns, trauma history, and strengths]
• Engagement capacity: [Ability and willingness to participate in proposed interventions]

Treatment & Behavior Support Plan

(Organize by target behavior. Interventions should progress from least to more restrictive, be IDT-actionable, and clearly operationalized for direct care staff.)

[Target Behavior Name]

• Goal(s): [Measurable, time-bound goal with baseline and target frequency/severity]
• Antecedent/prevention strategies: [Consistent staffing, predictable routines, pain checks before transfers, toileting offers, reduce overstimulation, offer choices, environmental modifications]
• Communication strategies: [One-step directions, slow pace, neutral tone, validation, avoid arguing about delusions, visual cue cards, interpreter use]
• Resident-facing coping strategies: [Feasible techniques: grounding, pleasant events, simple coping statements] (Include only if resident can participate.)
• Response/consequence strategies: [Staff response to calm behavior; staff response to escalation; step-back and re-approach protocol; PRN parameters per prescriber orders]
• Staff training needs: [De-escalation, trauma-informed care, psychosis communication, behavior tracking procedures]
• Clinical coordination: [Recommendations for medical evaluation, psychiatry/prescriber review of psychotropics, lab monitoring]
• Monitoring: [Tracking method; review interval; criteria for plan modification or escalation]
• Contingency planning: [After-hours protocol; criteria for contacting provider or emergency services]

(Repeat above structure for additional target behaviors as needed.)

Coordination & Follow-Up

• Care plan updates: [Specific behavior interventions, triggers, and preferred approaches to add/update in facility care plan]
• Contacts today: [Who was notified/updated; agreements reached]
• Follow-up plan: [Next visit timeframe; additional collateral to obtain; planned reassessment of behaviors and risk; review date for tracking data]

Clinician Signature: [Name, credentials]   Date/Time: [Signature date/time]

Psychotherapy time: [Start–stop time or total face-to-face time] (Include only if billable psychotherapy component provided. Maintain detailed process notes separately per organizational policy.)