Clinical Assessment V 1.0
Client ID #: (do not use name)
Ethnicities:
Primary Language:
1301
AF: Caucasian; AM: Venezuelan-American
 Eng  Span  Other:________
List all Participants/Significant Others: Put a [] for Identified Patient (IP); [] for Sig. others who WILL attend; [X] for Sig. others who will NOT attend
Adult: Age: Profession/Employer
Child: Age: School/Grade
[ ] AM 34:_Manager rental car agency___
[ X ] CM 3:_Daycare_____________________________________
[ ] AF 32: Secretary at insurance agency
[ X] CF6:First grade___________________________________
[ ] AF/M #2:_____________________________________________
[ ] CF/M____:____________________________________________
Presenting Problems
 Depression/hopelessness
Complete for children:
 Couple concerns
 Anxiety/worry
 School failure/decline performance
 Parent/child conflict
 Truancy/runaway
Anger issues
 Partner violence/abuse
 Fighting w/peers
 Loss/grief
 Divorce adjustment
 Hyperactivity
 Suicidal thoughts/attempts
 Remarriage adjustment
 Wetting/soiling clothing
 Sexual abuse/rape
 Sexuality/intimacy concerns
 Child abuse/neglect
 Alcohol/drug use
 Major life changes
 Isolation/withdrawal
 Eating problems/disorders
 Legal issues/probation
 Job problems/unemployed
 Other: _______________________________  Other: _______________________________
Interpersonal issues
 NA
Mood
Affect
Sleep
Eating
Anxiety Symptoms
Trauma Symptoms
Psychotic symptoms
Motor activity/Speech
 NA
 NA
 NA
 NA
NA
 NA
 NA
 NA
Thought
 NA
Socio-Legal
Other Symptoms
NA
Mental Status for IP (AF)
Conflict Enmeshment Isolation/avoidance Emotional disengagement  Poor social skills Couple
problems  Prob w/friends Prob at work Overly shy Egocentricity Diff establish/maintain relationship Other:
Depressed/Sad Hopeless Fearful Anxious Angry Irritable Manic Other:
Constricted Blunt Flat Labile  Dramatic Other:
Hypersomnia Insomnia Disrupted Nightmares Other:
Increase Decrease Anorectic restriction Binging  Purging Body image Other:
Chronic worry Panic attacks Dissociation Phobias Obsessions Compulsions Other:
 Acute  Chronic  Hypervigilance  Dreams/Nightmares  Dissociation  Emotional numbness  Other:
Hallucinations Delusions Paranoia Loose associations Other:
Low energy Restless/Hyperactive Agitated  Inattentive  Impulsive  Pressured speech  Slow speech
Poor concentration/attention Denial Self-blame Other-blame Ruminative Tangential Illogical
Concrete Poor insight Impaired decision making Disoriented Slow processing Other:
Disregards rules Defiant Stealing Lying Tantrums Arrest/incarceration Initiates fights Other:
 NA
Diagnosis for IP (AF)
Contextual Factors considered in making Dx:  Age  Gender  Family dynamics  Culture Language  Religion  Economic
 Immigration  Sexual Orientation Trauma Dual dx/comorbid  Addiction  Cognitive ability Other:___________________
Describe impact of identified factors:_Couple going through difficult time adjusting to have children; each has different gender role expectations for other as
parent based on culturally informed gender roles.
Axis I Primary: 309.28 Adjustment Disorder with Mixed Mood Anxiety and
List DSM Symptoms for Axis I Dx (include frequency and duration for
Depressed Mood, Chronic
each). Client meets__5___ of __5___criteria for Axis I Primary Dx.
Secondary: V61.10: Partner relational problem
1._Stressor: Birth of second child; couple still not adjusted to change
Axis II:_V71.09 None__________________________________________
2. Periods of sadness/hopeless; most days
Axis III: None reported_________________________________________
3._Periods of irritability and poor impulse control; 1-2 times per week
 Problems with primary support group: Spouse; parenting
 Problems related to social environment/school: Move
4. On-going conflict with AM
 Educational problems
5. On-going worry: most days.
 Occupational Problems
 Housing problems
6. Does not qualify for mood/anxiety disorder; no bereavement
 Economic problems
Medications (psychiatric & medical) Dose /Start Date
 Problems with accessing health care services
1._Celexa_/_40 mg; 9/1/09 (prior to start therapy)
 Problems related to interactions with the legal system
 Other psychosocial problems
2.___________________________/____mg;_____________________
Axis V: GAF ___60_____ GARF 55
3. __________________________/_____mg;_____________________
Have medical causes been ruled out?  Yes  No  In process
Has patient been referred for psychiatric/medical eval?  Yes  No
Client response to diagnosis:  Agree;  Somewhat agree  Disagree;
Has patient agreed with referral? Yes  No NA; prior tx
 Not informed for following reason:____________________________
List psychometric instruments or consults used for assessment:  None or
__Outcome rating scale_____________________________________
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Interpersonal issues
 NA
Mood
Affect
Sleep
Eating
Anxiety Symptoms
Trauma Symptoms
Psychotic symptoms
Motor activity/Speech
 NA
 NA
 NA
 NA
 NA
 NA
 NA
 NA
Thought
 NA
Socio-Legal
Other Symptoms
NA
Mental Status for IP (AM)
Conflict Enmeshment Isolation/avoidance Emotional disengagement  Poor social skills Couple
problems  Prob w/friends Prob at work Overly shy Egocentricity Diff establish/maintain relationship Other:
Depressed/Sad Hopeless Fearful Anxious  Angry Irritable Manic Other:
Constricted Blunt Flat Labile  Dramatic Other:
Hypersomnia  Insomnia Disrupted Nightmares Other:
Increase Decrease Anorectic restriction Binging  Purging Body image Other:
Chronic worry Panic attacks Dissociation Phobias Obsessions Compulsions Other:
 Acute  Chronic  Hypervigilance  Dreams/Nightmares  Dissociation  Emotional numbness  Other:
Hallucinations Delusions Paranoia Loose associations Other:
Low energy Restless/Hyperactive Agitated  Inattentive  Impulsive  Pressured speech  Slow speech
Poor concentration/attention Denial Self-blame Other-blame Ruminative Tangential Illogical
Concrete Poor insight Impaired decision making Disoriented Slow processing Other:
Disregards rules Defiant Stealing Lying Tantrums Arrest/incarceration Initiates fights Other:
 NA
Diagnosis for IP (AM)
Contextual Factors considered in making Dx:  Age  Gender  Family dynamics  Culture Language  Religion  Economic
 Immigration  Sexual Orientation Trauma Dual dx/comorbid  Addiction  Cognitive ability Other:___________________
Describe impact of identified factors:_Couple going through difficult time adjusting to have children; each has different gender role expectations for other as
parent based on culturally informed gender roles.
Axis I Primary: 309.4 Adjustment Disorder with Depressed Mood
List DSM Symptoms for Axis I Dx (include frequency and duration for
Secondary: V61.10: Partner relational problem
each). Client meets___5__ of __5___criteria for Axis I Primary Dx.
Axis II:_V71.09 None__________________________________________ 1._ Trigger: AF becoming increasingly unhappy with him following birth of
Axis III: None reported_________________________________________
second child; couple still not adjusted to change.
Axis IV:
2. Periods of sadness/hopeless following arguments (1-4 times/week)
 Problems with primary support group: Spouse; parenting
 Problems related to social environment/school: Move
3._Periods of irritability and poor impulse control (1-4 days/week)
 Educational problems
4. On-going conflict with AF_
 Occupational Problems
 Housing problems
5. Does not qualify for mood disorder; no bereavement
 Economic problems
6. ____________________________________________________
 Problems with accessing health care services
 Problems related to interactions with the legal system
Medications (psychiatric & medical) Dose /Start Date
 Other psychosocial problems
1._NA__________________________/____mg;____________________
Axis V: GAF ___60_____ GARF 55
2.___________________________/____mg;_____________________
Have medical causes been ruled out?  Yes  No  In process
Has patient been referred for psychiatric/medical eval?  Yes  No
3. __________________________/_____mg;_____________________
Has patient agreed with referral?  Yes  No  NA
List psychometric instruments or consults used for assessment:  None or Client response to diagnosis:  Agree;  Somewhat agree  Disagree;
 Not informed for following reason:____________________________
__Outcome rating scale_____________________________________
Medical Necessity: Check all that apply  Significant impairment  Probability of significant impairment  Probable developmental arrest
Areas of impairment:  Daily activities  Social relationships  Health  Work/School  Living arrangement  Other:_______________________
Risk Assessment
Suicidality:
 No indication
 Denies
 Active Ideation
 Passive Ideation
 Intent without plan
 Intent with means
 Ideation in past yr
 Attempt in past yr
 Family/peer hx of
completed suicide
Homicidality:
Hx Substance:
Sexual & Physical Abuse and Other Risk Factors:
 Current child w abuse hx: Sexual;Physical;Emotional;Neglect
 No indication
Alc abuse:  No
 Adult w childhood abuse: Sexual;Physical;Emotional;Neglect
 Denies
indication  Denies
 Adult w abuse/assault in adulthood: Sexual; Physical; Current
 Active Ideation
 Past  Current:
 Passive Ideation
Freq/Amt: _____________  History of perpetrating abuse: Sexual; Physical
 Elder/Dependent Adult Abuse/Neglect
 Intent w/o means
Drug:  No indication
 Anorexia/Bulimia/Other eating disorder
 Intent with means  Denies  Past
 Cutting or other self harm: Current; Past; Method:_____________
 Ideation in past yr  Current
 Violence past yr
Drugs:________________  Criminal/legal hx:__________________________
 Hx assault/temper
Freq/Amt:_____________  None reported
 Family/sig.other abuses
 Cruelty to animals
Indicators of Safety:  At least one outside person who provides strong support  Able to cite specific reasons to live, not harm self/other  Hopeful
 Has future goals  Willing to dispose of dangerous items  Willingness to reduce contact with people who make situation worse  Willing to
implement safety plan, safety interventions  Developing set of alternatives to self/other harm
 Sustained period of safety: ________  Other:
Safety Plan includes:  NA Verbal no harm contract  Written no harm contract  Emergency contact card  Emergency therapist/agency
number  Medication management  Specific plan for contacting friends/support persons during crisis  Specific plan of where to go during crisis 
Specific self-calming tasks to reduce risk before reach crisis level (e.g., journaling, exercising, etc.)  Specific daily/weekly activities to reduce stressors
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 Other:
Notes: Legal/Ethical Action Taken:  NA__________________________________________________________________________________
Case Management
Patient Referrals and Professional Contacts
Has contact been made with Social Worker:  Yes  No: explain:________________  N/A
Has client been referred for medical assessment:  Yes  No evidence for need
Has client been referred for psychiatric assessment:  Yes; cl agree;  Yes, cl disagree  Not rec.
Has contact been made with treating physicians or other professionals: Yes  No  N/A
Has client been referred for social services:  Job/training  Welfare/Food/Housing  Victim
services  Legal aid  Medical  Other:_______________________  N/A
Anticipated forensic/legal processes related to treatment:  No;  Yes_Potential divorce_________
Has client been referred for group or other support services:  Yes  No  None recommended
Client social support network includes:  Supportive family;  Supportive partner;  Friends;
 Religious/spiritual organization;  Supportive work/social group;  Other___________________
Anticipated effects treatment will have on others in support system?: (Parents, children, siblings, sig.
other, etc.): If couple issues not addressed, likely to affect children’s behavior._________________
Is there anything else client will need to be successful?____________________________________
Date 1st Visit: 11/1/09 Last visit: 11/14/09
Session Freq:  Once week  Every other
week  Other:________________
Expected Length of Treatment:3 months
Client Sense of Hope: Little 1----AF----------------5----AM---------------10 High Hope
If Child/Adolescent: Is Family Involved?
 Yes  No
Modalities: Individual Adult
Individual Child
Couple
Family
Group: _________
Is client involved in mental health or other
medical treatment elsewhere?
 No
 Yes:________________________
Expected Outcome and Prognosis:
 Return to normal functioning
 Expect improvement, anticipate less than normal functioning
 Maintain current status/prevent deterioration
Evaluation of Assessment/Client Perspective
How was assessment method adapted to client needs? Used tone, language comfortable for couple; allow each person to share perspective.
Age, culture, ability level, and other diversity issues adjusted for by: Provided opportunity for each to verbalize cultural/gender expectations.
Systemic/family dynamics considered in following ways: Address over/underfunctioning dynamic by allowing each to speak for self; assign AM task of
rescheduling appts.
Describe actual or potential areas of client-therapist agreement/disagreement related to the above assessment: Couple seems to see situation as
personality rather than cultural/gender conflict.
______________________________________________,_______________
Therapist Signature
License/intern status
_____________
Date
______________________________________________,_______________
Supervisor Signature
License
_____________
Date
Abbreviations: AF: Adult Female; AM: Adult Male; CF#: Child Female with age, e.g. CF12; CM# Child Male with age; Hx:
History; Cl: Client.
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