Case Analysis

54 3 ASSESSMENT AND DIAGNOSIS

Sample Assessment Form

INITIAL CLINICAL ASSESSMENT

Identifying Data

Name of Client:

Date:

DOB: Age:

Sex: Sexual Preference:

Marital Status:

Children:

Race/Ethnicity:

Religious Preference:

Client-Identified Problem (Client's Own Words) and Referral Source

1. History of current illness

A. Stressors and symptoms: include current stressors and detailed chronologic history of symptoms for each diagnosis on axes I and Il. Detail current substance abuse and the amount and pattern of use.

B. Recent suicide or homicide ideation or behavior: include all ideation, gestures, attempts, presence or absence of hopelessness, and extent of actions or plans in the past month.

2. Psychiatric history

A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including treatment modalities such as hospitalizaüon, psychotherapy, and medications and their dosages.

B. History of tauma: list the 10 most significant traumas. Do a timeline, and rate the disturbance for each event on a scale of 0 to 10; you can also ask for significant positive and negative events in the person's life. Administer the Impact of Events Scale and Dissociative Experiences Scale if trauma is suspected or reported.

C. History of violence To self:

To others:

To property:

3. Psychiatric review of systems: circle all relevant symptoms, and add any not listed

A. Mood: sadness, tearfulness, depressed mood, irritability, fatigue, lethargy, anergia, anhedonia, sleep changes, appetite changes, decreased libido, hopelessness, helplessness, worthlessness, suicide ideation, homicide ideation, spending sprees, increased energy or acüvity, decreased need for sleep, increased libido, pressured speech, tangentiality, and flight of ideas.

3 ASSESSMENT AND DIAGNOSIS 55

B. Anxiety: anxious mood, excessive worry, shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of impending doom, fear of death or collapse, cold/clammy skin, and tingling sensations in extremities.

C. Thought disorder: auditory or visual hallucinations, other hallucinations, ideas of reference, paranoia, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity, tangentiality, looseness of associaüons, and bizarre behavior.

4, Drug and alcohol history

A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including modalities such as hospitalizaüon, psychotherapy, and medications and their dosages. B. Substance abuse profile:

Substance	Current Amount	Date Last Used
Alcohol (use CAGE if abuse suspected but denied)
Tetrahydrocannabinol (THC)
Cocaine, crack, speed
LSD, mescaline, psilocybin
Barbiturates, other sedatives
Caffeine, tobacco
Over-the-counter drugs, herbal medications

5. Medical history: List significant past illnesses, surgeries, or hospitalizations A. Primary care physician:

B. Allergies:

C. Medications: use the table to document:

Current Medication	Dosage	Taken as Prescribed?
		Yes	No

6. Psychosocial history

A. Education:

B. Family relationships, social relationships, and abuse history:

C. Employment record and military history:

D. Religious background, belief system, or meaning framework:

E. Client's strengths: include client resources and how client self-soothes and manages stress.

7. Family history

A. Genogram:

CASE FORMULATION

Assessment of suicide or violence risk:

recommendations:

Admit to:

One-Mme

Refer to:

56 3 ASSESSMENT AND DIAGNOSIS

Referred for:

Physical examination

Individual psychotherapy

Psychological testing

Group psychotherapy

Hospitalization tions

Support group

Community support program services

Diagnostic summary:

Axis	Diagnoses, Factors, or Status	Codes	Alternatives to Rule Out
l. Clinical psychiatric syndromes	2. 3.
Il. Personality and specific development disorders	2. 3.
Ill. Medical problems	2. 3.
IV. Psychosocial stressors*	2. 3.
V. Global assessment of functioning (GAF)	Current GAF Highest GAF in past year
*Prioritize and rank severity: 1, none; 2, mild; 3, moderate; 4, severe; 5, extreme; 6, catastrophic; 7, unspecified.

Clinician's signature:

Date:

Location of assessment:

Adapted from Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders.