Ben case

1. Appearance

a. Physical Appearance. Client appears stated age, appears older, or appears younger, hairstyle, fingernails, and so on.

b. Dress. Appropriate, clean, pressed, wrinkled, disheveled, and so on.

c. Hygiene. Clean, well groomed, presence of body odor, and so on.

2. Behavior and Mannerisms

a. Gait limping, slow, hurried, and so on.

b. Posture. Slumped or rigid.

c. Eye Contact.

d. Mannerisms. Foot tapping, eye blinking, hand rolling, head nodding, and so on.

3. Attitude

a. Toward Interviewer.

b. Toward Treatment.

c. Toward Others.

4. Mood and Affect

a. Mood. Sad, elated, happy, bored, and so on.

b. Affect. Outward expression of mood such as smiling, frowning, crying, or laughing.

c. Appropriateness. Does the affect match the mood and the situation?

5. Speech

a. Quantity. Talkative, poverty of speech, and so on.

b. Quality. Circumlocution, monotonous, loquacious, loud, and so on.

c. Rate of Production. Mumbles, slow production, pressured speech, and so on.

6. Perceptual Disturbances

a. Hallucinations. False perceptions.

b. Illusions. Misperceptions of reality.

7. Thought

a. Thought Content. Delusions, obsessions, phobias, suicidal ideation, homicidal ideation, and so on.

b. Thought Processes. Flight of ideas, poverty of thought, relevancy, and so on.

8. Sensorium and Cognition

a. Alertness. Awareness of surroundings, goal-directed thinking, responding to the environment, and so on.

b. Orientation. Person, place, time, and situation.

c. Memory and Concentration. Remote, recent past, recent, and immediate recall.

d. Abstract Thinking. Conceptual thinking, ability to understand abstract ideas, ability to use inductive and deductive reasoning.

e. Intellect and Fund of Knowledge basic knowledge and intelligence.

9. Impulse Control

a. Sexual. Ability or lack of ability to control sexual impulses.

b. Physical. Ability or lack of ability to control physical impulses such as hitting, biting, or yelling.

c. Social. Ability or lack of ability to control social impulses.

10. Judgment and Insight

a. Social Judgment. Awareness of others, empathy, social decision making, and so on.

b. Insight. Awareness and understanding of one’s mental illness, insight into cause, effect, and course of illness.

c. Reliability. Is the client a good source of information, is he or she honest, aware, and able to report to the therapist his or her daily happenings?