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Behavioral Health Therapist
15-20 minutes

Psychiatric Evaluation HEADSS Assessment

This mental health note template by s10.ai is expertly crafted for mental health counselors performing a HEADSS assessment, encompassing critical areas like home environment, education, activities, substance use, sexuality, mental health, and safety. This all-inclusive template aids clinicians in collecting vital information to comprehend the patient's psychosocial background. Perfect for mental health professionals, it guarantees a comprehensive evaluation of adolescent patients, enhancing effective treatment planning. When integrated with s10.ai, the AI medical scribe, it optimizes documentation processes, enabling counselors to dedicate more time to patient care.

2,431 uses
4.4/5.0
A
Aarav Patel
Template Structure

Organized sections for comprehensive clinical documentation

HEADSS evaluation:
Home Environment:
- [describe living situation, family dynamics, relationships with family members] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Education and Employment:
- [describe school performance, attendance, relationships with teachers and peers, employment status, job satisfaction] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Activities:
- [describe hobbies, interests, extracurricular activities, peer relationships, social interactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Substance Use:
- [mention use of tobacco, alcohol, and other substances, frequency and context of use] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sexuality:
- [describe sexual activity, orientation, relationships, contraception use, sexual health concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suicide/Depression:
- [mention any feelings of sadness, hopelessness, self-harm, suicidal thoughts or attempts, mental health history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Safety:
- [describe any concerns about personal safety, experiences with violence or abuse, safety at home, school, or work] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

HEADSS assessment:
Home Environment:
- The patient resides with their parents and two younger siblings. Family interactions are generally positive, characterized by open communication and supportive relationships.
Education and Employment:
- The patient is a high school junior with average academic performance. Attendance is regular, and they maintain a good relationship with teachers and classmates. The patient is employed part-time at a local café and expresses satisfaction with the job.
Activities:
- The patient enjoys playing basketball and is a member of the school team. They have a close group of friends and participate in regular social activities.
Drugs:
- The patient occasionally drinks alcohol at social events but denies using tobacco or other substances.
Sexuality:
- The patient identifies as heterosexual and is in a monogamous relationship. They consistently use contraception and have no sexual health concerns.
Suicide/Depression:
- The patient experiences occasional feelings of sadness but denies any history of self-harm or suicidal ideation. They have a supportive mental health background with regular counseling sessions.
Safety:
- The patient feels safe at home and school. There are no reported incidents of violence or abuse.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The HEADSS assessment template is an essential tool for healthcare professionals seeking a comprehensive understanding of adolescent health and well-being. This structured framework facilitates a thorough evaluation of key areas such as home environment, education and employment, activities, substance use, sexuality, mental health, and safety. By utilizing this template, clinicians can systematically gather critical information, enabling them to identify potential risk factors and provide targeted interventions. The HEADSS assessment is designed to enhance clinical efficiency and improve patient outcomes, making it an invaluable resource for practitioners committed to delivering holistic adolescent care. Explore the benefits of implementing this template in your practice to ensure a proactive approach to adolescent health management.
Frequently Asked Questions

Common questions about this template and its usage

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Psychiatric Evaluation HEADSS Assessment