Model for Assessment of the Individual and Format for Report
I.
Demographic Information: Age, Sex, Marital Status, Education Level, Occupation, Living situation
II.
Reason for Referral—Purpose of Interview
III.
Mental Status Exam (including Physical Description and Behavioral Observations)
a. attitude towards interview: cooperative, open, defensive etc.? How they experienced interview
situation: exciting, difficult, challenging?
b. orientation to person, place, time and situation
c. verbal statements vs. nonverbal cues (i.e., congruence or incongruence?)
d. expression of affect appropriate to content? Able to engage in variable affect according to the
context? Is affect congruent with mood?)
e. thought process and content; suicidal ideation, memory/attention, sleep, appetite, judgment,
insight, estimate of intellectual functioning
IV.
Tests / Assessments Administered (if applicable)
V.
Background Information and Psychosocial History
Life Areas
1. Education/occupation (also military history)
a. Achievement; progress
b. satisfaction with…
c. problems
2. Relationships with significant others in early life
a. parental messages
b. description of parents—ages, occupations, personalities
c. nature of parental relationship
d. degree of closeness of parents with child
e. sibling relationships
f. earliest memory or other memorable early life experiences
g. medical, psychological, environmental obstacles to developmental maturation
3. Family relationships currently
a. similarity or dissimilarity to earlier family relationships
4. Current relationships with significant others
a. close friends—both sexes
b. dating and marital history; sex life and maturity
c. children
5. Medical history
6. Psychological treatment history (e.g., hx counseling; psych medications; inpatient
7. Substance use and misuse (alcohol, tobacco, other drugs; other potentially addictive behaviors; tx hx)
8. Legal, criminal problems
9. Interests/ fun activities; social participation; faith community; what is typical day like?
10. Planning for the future/goals and philosophy of life/stated coping mechanisms
VI.
Test / Assessments Results (if applicable)
VII.
Conceptualization/ Formulation: Major hypotheses about individual’s strengths and
weaknesses along with supports and stressors. (see handout on conceptualization. Do not try to
summarize every domain below, but make judgments on what are most critical)
Assessment of above life areas may be in relation to the following variables:
A. Person functioning at appropriate developmental, moral, physical levels?
B. Perceptions (i.e., individual’s own perceptions, others’ perceptions, comparisons with
normative data – inconsistencies between perceptions of self and others?)
C. Expectations and standards for self—implications
1. Normal and appropriate?
2. Definition of success; perfectionism, etc
3. How does person explain where they are in life?
D. How person feels about himself/herself
1. Body image
2. Description
3. How they think others view them
E. How person is likely to trigger others to feel
1. Implications
2. Most outstanding characteristics of ways they relate to others—implications
3. Behaviors which would facilitate relationships
4. Behaviors which would hinder relationships
5. How others feel about them
F. Behaviors denied which most people would admit as being conflict areas
G. Ways of handling problem situations and conflicts
1. Coping strategies
2. Implications, consequences of behavioral tendencies or personality style
3. Defense mechanisms
H. How person makes sense of events around them
1. Major hypotheses of life—implications
2. Value system and other motivational factors
VIII. Problem analysis (include DSM-5 diagnoses and/or “rule-outs”, other specified disorder)
IX.
Treatment plan/therapy recommendations (use Treatment Planner & other resources as needed)
Brief summary of treatment modality recommended (e.g., individual; couple; whole family; group
referral; or combination), frequency of contacts, duration of contacts, suggested gender, experience
level, and theoretical orientation of therapist, etc.
SUGGESTED FORMAT
Problem Area 1: (diagnosis; behavioral definitions)
Long-term goals:
Short term objectives:
Interventions:
Problem Area 2:
Long-term goals:
Short term objectives:
Interventions:
Problem Area 3:
Long-term goals:
Short term objectives:
Interventions: