Maine DHHS - Questionnaire - Adult Needs and Strengths Assessment (ANSA)


Status: Incomplete
   

Adult Needs and Strengths Assessment (ANSA)


1. Person Completing Form:


Instructions: Please list phone number in the following format: ###-###-####

2. Phone Number:


Instructions: LIFE DOMAIN FUNCTION (0 = No evidence of problems, 1 = History, Mild, 2 = Moderate, 3 = Severe)

3. Physical/Medical:

(Please select one.)


4. Family: (life domain)

(Please select one.)


5. Employment: (Please complete Module 1 if scored 1, 2 or 3)

(Please select one.)


6. Social Functioning:

(Please select one.)


7. Recreational:

(Please select one.)


8. Intellectual: (Please complete Module 2 if scored 1, 2 or 3)

(Please select one.)


9. Sexuallity:

(Please select one.)


10. Living Skills:

(Please select one.)


11. Residential Stability:

(Please select one.)


12. Legal:

(Please select one.)


13. Sleep:

(Please select one.)


14. Self Care:

(Please select one.)


15. Decision-making:

(Please select one.)


16. Medication Adherence:

(Please select one.)


17. Transportation:

(Please select one.)

Instructions: STRENGTHS (0 = Centerpiece, 1 = Useful, 2 = Identified, 3 = Not yet identified)

18. Family: (strengths domain)

(Please select one.)


19. Social Connectedness:

(Please select one.)


20. Optimism:

(Please select one.)


21. Talents/Interest:

(Please select one.)


22. Educational:

(Please select one.)


23. Volunteering:

(Please select one.)


24. Job History:

(Please select one.)


25. Spiritual/Religious:

(Please select one.)


26. Community Connection:

(Please select one.)


27. Natural Supports:

(Please select one.)


28. Resiliency:

(Please select one.)


29. Resourcefulness:

(Please select one.)

Instructions: ACCULTURATION (0 = No evidence, 1 = Minimal needs, 2 - Moderate needs, 3 = Severe needs)

30. Language:

(Please select one.)


31. Identity:

(Please select one.)


32. Ritual:

(Please select one.)


33. Cultural Stress:

(Please select one.)

Instructions: MENTAL HEALTH NEEDS (0 = No evidence, 1 = History or sub-threshold, watch/prevent, 2 = Causing problems, consistent with diagnosable disorder, 3 = Causing severe/dangerous problems)

34. Psychosis:

(Please select one.)


35. Impulse Control:

(Please select one.)


36. Depression:

(Please select one.)


37. Anxiety:

(Please select one.)


38. Interpersonal Problems:

(Please select one.)


39. Antisocial Behavior:

(Please select one.)


40. Adjustment to Trauma: (Please complete Module 3 if scored 1, 2 or 3)

(Please select one.)