DSM Assessment format to be used in 2nd assessment assignment, and guidelines for
completing the 2nd intervention assignment): (Note that the DSM assessment format is identical to that
provided in Pomeroy and Wambach’s The Clinical Assessment Workbook (2003) except for what is shaded below)
I.
Descriptive and Identifying Information: (some of this will have already been collected by the bookkeepers if
working in an agency, otherwise, you need to get this info) (The starred items are for you alone):
A. Name
B. Address
C. Date at birth
D. Occupation
E. Income
F. Gender
G. Ethnicity
H. Dress and appearance**
I. Personal hygiene**
J. Marital/Domestic Partnership status
K. Living arrangements (include names and relationship to client)
Omitted phone numbers and address for the sake of this assignment
II.
Description of Presenting Problem(s):
A. Specific description of the problem (including the client’s primary perception of the primary problem and, if
different, the problem that you chose to focus on; also, if the two are different, provide a brief explanation
of why you chose not to work on the problem identified by the client)
B. How long has the problem that you chose to focus on existed?
C. Has it occurred before?
D. What attempts has the client made to resolve the problem? If it is a recurrent problem, what seemed to
help resolve it in the past?
E. What kinds of resources does the client have to help resolve the problem? Has he or she sought or received
any treatment for this problem?
F. Why did the client seek help now?
G. When asked the miracle question, or a functional equivalent, what is the client’s “ideal vision” of what they
would like their life to be like?
H. According to the change framework handout, what stage of change is the client at and on what basis did you
make this determination?
III. Developmental History (NOTE: For adult clients, little detail is usually sought in this section other than possibly
asking if there was anything unusual about their early years. For children, the following information is
usually gathered from their parents or primary caregivers):
A. Was the pregnancy planned?
B. Were there any problems during the pregnancy?
C. Were any medications or other substances used during the pregnancy? If so, what and when?
D. Were labor and delivery uneventful? If not, what happened?
E. Was the child born with any unusual medical conditions or physical problems?
F. Did the child have a consistent caregiver during the first two years? Who?
G. If known, what was the predominant parent-infant attachment pattern?
H. Did the child crawl, walk, talk, and toilet train at the expected times? When?
I.
J.
What opportunities did the child have to associate with same-age peers?
Has the child incurred any significant problems or delays in school?
IV. Mental Status
A. Cognitive Functioning:
1. Does the client seem to be of normal intelligence?
2. Is the client oriented to person, place, and time? How can you tell?
3. Is there evidence of logical problem-solving thinking or capacities? How can you tell?
4. Does the client seem preoccupied by anything? If so, what?
5. Is there evidence of delusional thinking? If so, are delusions bizarre (include description of specific
content)
6. Is the client’s thinking coherent and goal directed? (How can you tell? Speech pattern & content)
7. Does the client exhibit good judgment? (How is that demonstrated? If poor judgment, how is that
demonstrated?)
8. Does the client show any memory problems? If so, are they immediate, recent, or remote?
9. Does the client report hearing or seeing things that others don’t seem to hear or see? Do you observe
any behaviors that indicate client listening to an internal voice or seeing things that you don’t?
10. Is there anything unusual about the client’s manner of speaking?
B.
Emotional functioning:
1. What emotions does the client describe in relation to the presenting problem?
2. Do the client’s emotions appear to be congruent with the client’s thoughts?
3. How has the client been feeling the majority of time over the past year?
4. Has the client’s emotional state created difficulties for the client recently? Over the past year?
5. How stable are the client’s emotions during the interview?
6. Does the client exhibit any blunting or flattening of affect?
7. Does the client seem unusually animated or expansive in his or her expression of emotions?
C.
Physical functioning:
1. Does the client’s level of energy or activity seem unusual (e.g. lethargy or hyperactivity or normal
range?)
2. Does the client display any odd or peculiar motor behaviors (e.g. motor and/or vocal tics, mannerisms,
or stereotypical movements)?
3. Does the client report any medical conditions or problems? Identify and describe thoroughly.
4. Has the client been examined by a physician during the past year? Who and where and when? Results
of the exam?
5. Does the client take any prescription medications on a regular basis or irregular basis? What, how
much, prescribed by whom? Do they work, not work? Side effects? Positive effects? Negative effects?
6. Does the client take any over-the-counter medications on a regular basis? What, how much, how often?
7. Does the client present with any disabilities? Which ones, degree of disability, special needs.
D. Substance Use*:
1. Does the client use alcohol? If yes, what kind, how often, how much at one setting?
*
In this and any other appropriate section, please indicate any rapid assessment instruments used.
2. Does the client use any other substances? If yes, what kind, how often, how much?
3. Has the client experienced any social (including relationships both casual and intimate), occupational, or
legal problems associated with his or her use of alcohol and/or other drugs?
4. Has anyone ever encouraged the client to stop or cut back his or her use of substances?
5. Has the client ever been treated for a drug or alcohol problem?
V.
Relational Functioning
A. Family
1. Does the client reside with other family/friends? With whom, how long?
2. What is the client’s relationship with other family members?
3. Does the client’s presenting problem involve any other family members? Who, how long, why?
4. Is there any history of family problems? Have any family members had problems similar to the
client’s current situation?
5. Would family members be willing to participate in treatment if necessary?
B.
Significant other
1. Does the client have a relationship with a significant other? Who?
2. If so, what is the length of the relationship? The quality?
3. Does the client’s presenting problem involve the significant other?
4. Would the significant other be willing to participate in treatment if necessary?
C.
Social support system
1. Does the client have close friends and/or acquaintances?
2. What is the quality of these relationships?
3. Does the client feel that these are supportive relationships and is satisfied with them?
4. Are any members of the client’s social support system involved in the presenting problem?
VI. Occupational/School Functioning
A. Employment
1. Is the client employed? Underemployed? Unemployed?
2. If so, where is the client employed? Full-time, part-time, how many hours a week? Shifts?
3. What is the client’s occupation? History of occupations?
4. If the client is not employed, is she or he retired?
5. Does the client’s presenting problem affect his or her job?
B.
School
1. Is the client a student? Full-time? Part-time?
2. What is the client studying?
3. Does the client’s presenting problem affect his or her studies?
VII. Legal Problems
A. Does the client have current or past problems with the legal system?
B. If so, what types of problems?
C. If history, what types of problems?
D. Has the client ever been convicted of a crime? What crime? What punishment or legal consequence?
VIII. Diversity Issues
A. What is the client’s ethnicity?
B. What is the client’s nationality?
C. If relevant, immigration status?
D. Is English the client’s first language? Second, third?
E. What are some of the client’s beliefs about mental illness?
F. Does the client engage in any religious or spiritual practices?
G. Has the client discussed his or her sexual orientation?
H. Does the client utilize any cultural resources?
I. Does the client perceive barriers to accessing resources?
IX. Client’s Strengths and Resources:
A. What do you perceive to be the client’s personal and environmental strengths or potential strengths?
What does the client perceive?
B. How can these strengths be utilized to enhance coping?
C. What client personal or environmental resources could be utilized to enhance coping?
D. What agency resources could be utilized to intervene with client?
X. DSM diagnosis with brief explanation of why you chose this particular primary Axis I diagnosis over another
related diagnosis:
XI. Treatmetn Plan (to be completed for each problem you identify):
A. Problem
B. Operational definition
C. Goal
D. Meaureable objective
E. Primary intervention
As with the 1st Assessment/Intervention assignment, for one identified problem, document your REACH-SW search and
reasons you selected a particular intervention (addressing the 3 REACH-SW criteria for this). For all other identifed
problems, briefly state what intervention you chose and “why”.