CMHA 2016 BrainFX 360 Report Template

CMHA 2016 BrainFX 360 Report Template

    CID:

    Name:


BrainFx 360: Assessment Results & Recommendations


Name:


CID:


Date of Birth:


Assessment Date:


Primary Clinician:


CBA (if different):



Background and Presenting Concerns 


Client has been working with Primary Clinician as his/her primary clinician at CMHA since DATE. He/She presents with Diagnosis/Challenges. Recently, Client has been working with Primary Clinican on (ex. strategies to reduce anxiety, improving school/home performance). Client was referred for a BrainFx assessment with the purpose of identifying strengths and challenges in his/her neurofunction and how this may impact their daily functioning in self-identified goals of....


Results


At the time of assessment: 


Hours Slept


Additional comments/observations: related to fatigue, mood, pain (if any).

Fatigue Level (0-5)


Mood (0-10)


Pain (0-5)


Anxiety (Early) (0-4)


Anxiety (Late) (0-4)


Subjective Comments From Client


Clinical Observations


Additional information from Self/Companion Reports 



The results of the assessment demonstrate that Client obtained an overall score of average/below average/ above average compared to the population that has completed the BrainFX assessment. The chart below identifies skills that were much higher (strengths) or lower (challenges) than average scores. The skills not listed were reported as average when compared to the population. The BrainFx 360 assessment report is enclosed for reference and further detail. 




Areas of Strength

Areas of Challenge


1. Emotion Recognition

  • Definition: Ability to accurately identify emotions from facial expressions and body language.


2. Constructive Ability 

  • Definition:


3. Memory: Delayed, Written and Cued

  • Definition:


4. Abstract Reasoning

  • Definition:





1. Impulsivity

  • Definition: Displaying behaviour characterized by little or no forethought, reflection, or consideration of the consequences.


3. Memory: Immediate, Auditory, Complex, Novel

  • Definition:


4. Numerical Problem Solving

  • Definition:




Recommendations


The areas listed as areas of challenge are things that may have an impact on daily functioning in self-care, productivity, and leisure activities.  Everyone has areas that are identified as needing strategies to support success.  Please consider the following recommendations to promote success: 


Areas of Strength/Challenge

Description of Skill and Strategies to Improve Neurofunction

Impulsivity

Real Life Impact: Money management, medication management, emotional regulation, conflict resolution, risky behaviours (i.e. drug use, sexual activity), rushing through tasks at work or tests

Key Recommendation:  Consider all options and ensure that you fully understand the consequences before acting. 

  • Read instructions fully and ensure that you understand the task before participating
  • Ask questions if you do not understand
  • Pros/cons list to assist in decision making
  • Reflecting on the consequences of your choices afterwards

Skill

Real Life Impact:

Key Recommendation(s):

Skill

Real Life Impact:

Key Recommendation(s):

Skill

Real Life Impact:

Key Recommendation(s):

Skill

Real Life Impact:

Key Recommendation(s):




This report was prepared by:



_________________________            _____________________________

Clinician, Position                    Date




_____________________________            _____________________________

Clinician, Position                    Date



1

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