HEEADSSS ASSESSMENT

Patient: [Name]
Age: [Age in years]
Date of visit: [Date]
Clinician: [Name, credentials]
Seen alone: [Yes or no, and for how long]
Parent or caregiver present for: [Parts of the visit, such as the history and the plan]

CONFIDENTIALITY
Explained to: [Adolescent, parent or caregiver, or both]
Limits explained: [Serious risk of harm to self or others, abuse, and what the law requires you to report]
Adolescent's understanding: [Agreed, and any questions]

HOME
Living situation: [Who lives at home, and any recent moves or changes]
Relationships: [How they get along, conflict, who they can talk to]
Concerns: [Violence at home, housing, or food worries]

EDUCATION AND EMPLOYMENT
School: [Grade, attendance, performance, recent changes]
At school: [Friends, bullying, connection with teachers]
Work and plans: [Job and hours, plans after school]

EATING
Eating pattern: [Meals, skipped meals, dieting]
Body image: [How they feel about their weight and shape]
Concerning behaviors: [Restricting, bingeing, purging, or excessive exercise]
Growth: [Weight, height, BMI percentile]

ACTIVITIES
Interests: [Sports, hobbies, clubs, faith, time with friends]
Screens and sleep: [Hours online, devices at night, hours of sleep]

DRUGS
Substance use: [Tobacco, vaping, alcohol, cannabis, other drugs; use by friends and family]
Screening tool: [Such as the CRAFFT or S2BI, with result]

SEXUALITY
Identity and relationships: [Sexual orientation and gender identity if shared, current relationships]
Sexual activity: [Ever sexually active, partners, consent, any pressure]
Sexual health: [Condoms, contraception, STI testing, pregnancy concerns, HPV vaccine]

SUICIDE AND DEPRESSION
Mood: [Low mood, irritability, anxiety, sleep, loss of interest]
Screening tool: [Such as the PHQ-A or ASQ, with result]
Self-harm and suicidal thoughts: [Ever and recent, intent, plan, past attempts]
Risk level: [Low, moderate, or high, with reasoning]

SAFETY
Injury prevention: [Seatbelts, helmets, driving, riding with impaired drivers]
Violence and abuse: [Fighting, bullying, dating violence, abuse, firearms at home and how stored]
Online safety: [Contact with strangers, sharing images, cyberbullying, exploitation]

STRENGTHS
Strengths and supports: [What the adolescent is good at or proud of, and trusted adults]

SUMMARY
Key concerns: [Main problems or risks identified]
Overall picture: [How the concerns and strengths fit together, and the level of concern]

PLAN
Counseling given: [Topics discussed, and the adolescent's response]
Referrals: [Mental health, sexual health, school support, or other]
Safety plan: [If needed: warning signs, coping steps, contacts, emergency steps]
Shared with parent or caregiver: [What, with the adolescent's agreement]
Follow-up: [When, and how to reach the clinic confidentially]

Signed: [Clinician name, credentials, date and time]