124 (124)    MH REPORT (601.93)

.| .| Illness Management and Recovery Assessment for Behavioral Family Therapy| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: 
the way of your doing things that you would like to do or need to do?|     <*Answer_6805*>| 8. Relapse Prevention Planning: Which of the following would best describe what you know and have done in 
order to not have a relapse?|     <*Answer_6806*>| 9. Relapse of symptoms: When is the last time you had a relapse of symptoms (that is, when symptoms have gotten much worse)?|     <*Answer_6807*>| 
10. Psychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons?|     <*Answer_6808*>| 11. Coping: How well do you feel that you are 
coping with your mental or emotional illness from day to day?|     <*Answer_6809*>| 12. Involvement with self-help activities: How involved are you in consumer run services, peer support groups, 
Alcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other  similar self-help programs? |     <*Answer_6810*>| 13. Using medication effectively: How often do you take your 
medication as prescribed?|     <*Answer_6811*>| 14. Functioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships; to money, housing, 
and legal concerns; to difficulty showing up at   appointments or paying attention during them; or to increased symptoms. Over the past 3 months, how much did drinking get in the way of your 
functioning? |     <*Answer_6812*>| 15. Functioning affected by drug use. Using street drugs and misusing prescription or over-the-counter medication can interfere with functioning when it 
contributes to conflict in relationships; to   money, housing, and legal concerns; to difficulty showing up at appointments or paying attention during them; or to increased symptoms. Over the past 3 
months, how much did drug use get in the way of   your functioning? |     <*Answer_6813*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use 
<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | |      Total IMRA Score: <-IMRA->|   |      High scores indicate 
alone for diagnostic purposes.  Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.|  $~
more recovery and illness management skills.| |      Please indicate what stage of therapy you are at present|          <*Answer_6798*>| | Questions and Answers| | 1. Progress toward goals: In the 
past 3 months, you have come up with...|     <*Answer_6799*>| 2. Knowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication?|     
<*Answer_6800*>| 3. Involvement of family and friends in my mental health treatment: How much are family members, friends, boyfriends or girlfriends, and other people who are important to you 
(outside the mental health  agency) involved in your treatment? |     <*Answer_6801*>| 4. Contact with people outside of your family: In a normal week, how many times do you talk to someone outside 
of your family (a friend, co-worker, classmate, roommate, etc.)?|     <*Answer_6802*>| 5. Time in structured roles: How much time do you spend working, volunteering, being a student, being a parent, 
taking care of someone else or someone else's house or apartment? That is, how much time  do you spend doing activities that are expected of you for or with another person? (This would not include 
self-care or personal home maintenance.) |     <*Answer_6803*>| 6. Symptom distress: How much do symptoms bother you?|     <*Answer_6804*>| 7. Impairment of functioning: How much do symptoms get in