Help Needed

NAME(S):

DATE OF BIRTH:

PRIMARY LANGUAGE:

REFERRED BY:

INTAKE DATE:

EVALUATED BY:

DESCRIPTION OF CLIENT(S):

Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.

PRESENTING PROBLEM:

Describe the problem as the client has presented it, including perspective, function impairment, and symptoms.

HISTORY OF PROBLEM:

Describe the course of the problem and specific onset and symptoms.

MENTAL STATUS:

Activity:

Mood and Affect:

Thought Process, Content, and Perception:

Cognition, Insight, and Judgment:

Suicidal and Homicidal Assessment

If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

SOCIAL HISTORY:

Describe the client's present living situation:

Family:

School:

Health:

Occupational/Work:

Spiritual/Religious:

Legal:

Social History (include history of abuse/trauma):

HEALTH & WELLNESS HISTORY:

Substance use (including alcohol, drugs, tobacco and caffeine intake) :

Sleep habits:

Exercise habits:

Eating habits and appetite:

PREVIOUS THERAPY / PSYCHIATRIC SERVICES:

Have you ever been in counseling before? No Yes, Inpatient Outpatient Day Treatment

Name of Provider Clinic Year Diagnosis / Problem

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever seen a Psychiatrist before? No Yes, Inpatient Outpatient Day Treatment

Name of MD: _______________________________________ Clinic: _____________________________

Was any of your previous therapy related to substance abuse? No Yes

Have you ever had serious thoughts of suicide or homicide? No Yes

Have you ever made a suicide / homicide attempt? No Yes Explain: ____________________________

_____________________________________________________________________________________

Do you presently feel suicidal or homicidal? No Yes Explain: __________________________________

FAMILY RELATIONSHIP HISTORY:

Describe the client's current and historical family status and relationships, including during childhood/adolescence.

STRENGTHS:

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.

CHALLENGES

Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.

DIAGNOSIS:

Using the information gathered thus far, make a diagnosis using DSM 5.

DISCUSSION/CLINICAL FORMULATION:

Provide your rationale for the provided diagnosis. Describe the appropriate theory to consider using with this client. Note the basics of this theory and how it might apply to this client.

_________________________________________________ __________________

Student/Counselor in Training Date

_________________________________________________ __________________

Supervisor Date