CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 1 of 6
Revised 01/2012
Client Name: ___________________________________________
Date: _________________________
Presenting Problem and Client Strengths
Presenting Problem





Why is client coming to
treatment?
Precipitating Event?
Current Complaints,
Symptoms/Behaviors:
onset, duration, and
frequency?
What changes in
functioning (e.g., at home,
school, work, socially) has
client experienced?
Presenting crises, if any,
and how client is managing
them?
Client Strengths


What are client’s strengths?
What are client’s current
coping mechanisms?
Psychiatric/Counseling/Mental Health Treatment History

What is client’s previous
experience with therapy?

Client’s perceived benefits
or lack thereof re: previous
therapy?



Any history of suicidal
and/or homicidal
ideation/attempts?
Does client currently take
or have past history of
taking psychotropic
medication?
If yes, name of prescribing
physician and the
medication(s), dosage and
client’s perceived benefits?
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Client Name:
Agency:
ID#:
CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 2 of 6
Revised 01/2012
Family Developmental History and Current Living Situation
Family of Origin (FOO)






Composition of FOO?
Client’s relationship with FOO?
Significant events (deaths,
divorce, physical/sexual/verbal
abuse, serious illnesses, family
milestones, etc.)
Spoken/unspoken messages
client received from FOO and
culture/community?
FOO attitude towards significant
events
Client attitude towards FOO
Family History



Psychiatric/Mental Illness
Substance Abuse/Dependence
Legal Issues
Current Living Situation




What is client’s current living
arrangement?
Client’s feelings about current
living situation?
Any custody of children or
dependents?
Does client have financial, legal,
or immigration issues?
Relationship Status/History and Current Support System
Relationship Status/History



If coupled, how long and what is
quality of the relationship?
If single, is client dating or
interested in a relationship?
What is client’s relationship
history and what are client’s
interpersonal relationship
patterns (e.g., abuse,
codependence, etc.)?
Current Support System
Composition



Who is available to client for
emotional support?
Is support system aware of
client’s presenting problems?
What are the deficits in client’s
support system?
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Name:
Agency:
ID#:
CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 3 of 6
Revised 01/2012
Client Educational, Vocational, & Social History
Educational and Vocational
History





Client’s education history,
highest grade completed, and
attitude toward school?
Does client have educational
aspirations and/or goals? If so,
what?
Does client currently have
employment? Employment
satisfaction?
If client is unemployed, is client
satisfied with unemployment?
Goals for employment?
Significant events in clients’
educational/vocational history?
Social History



Client’s significant cultural,
ethnic, racial, class, religious,
and/or spiritual influences?
How have those influences
viewed client’s sexual and/or
gender identity?
What are the client’s
hobbies/social activities?
Drug/Alcohol/Addictive Behavior History





Past history of drug/alcohol
use/abuse (including onset,
frequency, quantity)? Treatment?
Current use/abuse of
drugs/alcohol (including onset,
frequency, quantity)?
Impact on client’s life and
relationships of drug/alcohol
use/abuse?
Client’s attitude toward
drug/alcohol use/abuse? Is client
attempting to stop/reduce use or
seek treatment?
Does client have other addictive
behaviors (e.g., food, gambling,
sex, video games, etc.)
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Name:
Agency:
CLINICAL ASSESSMENT
ID#:
CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 4 of 6
Revised 01/2012
General Medical History




History of significant
illnesses/injuries/allergies?
History of hospitalizations and/or
surgeries?
Does client have any permanent
disabilities?
Does client have a primary care
physician? If so, name and
phone?
Intimate Partner/FOO Domestic Violence Assessment












Frequency of conflicts & the
manner in which they are/were
resolved w/partner/FOO?
Interrogation about or restriction
of outside activities, associations,
and/or friends by client, partner,
or within FOO? If yes, describe
Name-calling, insults, threats by
client, partner, or within FOO
when angry? If yes, describe
Does client, partner, or those in
FOO have an explosive temper or
difficulty controlling anger? If
yes, describe
Hitting, shoving, kicking, or
throwing of objects by client,
partner, or FOO when angry? If
yes, describe:
Has client, partner, or FOO ever
required medical treatment as a
result of abuse? If yes, describe
Have law enforcement personnel
ever been involved because of
fighting or abuse? If yes, describe
Does client, partner, or FOO own
a weapon? If yes, describe
weapon, location, whether it is
locked, and the frequency &
purpose of use
What does client hope to
accomplish from
counseling/therapy at Agency
(e.g., increase self esteem,
support during coming out
process, working to build
LGBTQ support system, etc.)?
Client’s Expectations Of Therapy
What is client’s understanding of
and commitment to the
therapeutic process?
Is client in need of any referrals
at this time?
Any suggestions for reading for
client at this time?
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Referrals/Bibliotherapy
Name:
Agency:
CLINICAL ASSESSMENT
ID#:
CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 5 of 6
Revised 01/2012
Mental Status
Provide a word picture of the client based on your observations.
Be sure to address relevant features from each bolded category in the left column by
editing/changing the words under each heading.
Appearance
Dress, grooming, unusual
physical characteristics.
Behavior
Activity level, mannerisms, eye
contact, manner of relating to
parent/therapist, motor behavior,
aggression, impulsivity.
Appearance:
Client is a -year-old African American/Caucasian/Hispanic male/female who presented as his/her stated age.
He/She appeared clean/unkempt and was dressed casually/formally in a clean/rumpled/dirty pullover/longsleeve/short-sleeve shirt/blouse, clean/rumpled/dirty pants/jeans/dress, and shoes/sneakers. His/Her grooming
appeared poor/fair/age-appropriate. He/She appeared to have no unusual physical characteristics.
Behavior:
Client presented with low/moderate/high activity level, expressive hand and arm gestures to accentuate his/her
verbal content, and with poor/fair/good eye contact. He/She seemed to relate to this therapist/writer with some
degree of suspicion/guardedness/openness. Client appeared to have age-appropriate fine and gross motor
movement. He/She exhibited no overt aggression or impulsivity throughout the interview.
Expressive Speech
Fluency, pressure, impediment,
volume
Expressive Speech:
Client's speech exhibited fluency, articulation, and appropriate volume, with no sign of pressuring or impediment.
Thought Content
Fears, worries, preoccupations,
obsessions, delusions,
hallucinations
Thought Content:
Client's thought content exhibited no overt or excessive fears, worries, preoccupations, or obsessions. Client
denied any current or past delusions or hallucinations.
Thought Process
Attention, concentration,
distractibility, magical thinking,
coherency of associations, flight
of ideas, rumination, defenses
(e.g. planning)
Cognition
Orientation, vocabulary,
abstraction, intelligence
Mood/Affect
Depression, agitation, anxiety,
hostility absent or unvarying,
irritability
Thought Process:
Client's thought process exhibited coherency of associations and no difficulty with attention, concentration,
distractibility, magical thinking, flight of ideas, or rumination. Client's main defense appears to be
denial/planning/withholding/withdrawing/intellectualization/repression.
Cognition:
Client was oriented x4 (person, place, time, and situation). He/She appears to have an average/aboveaverage/below-average vocabulary and an average/above-average/below-average level of intelligence, with a
poor/fair/good degree of abstraction.
Mood/Affect:
Client presented with a relaxed/restricted/blunted/sad/angry affect and acknowledged/denied feelings of
depression and/or anxiety, with no/occasional/frequent feelings of agitation and/or irritability. He/She exhibited
no hostility throughout the interview.
Suicidality/Homicidality
Thoughts, behavior, stated intent,
risks to self or others
Suicidality/Homicidality:
Client denied any current or past history of suicidal ideation or attempts or of homicidal ideation or attempts.
Attitude/Insight/Strengths
Adaptive capacity, strengths &
assets, cooperation, insight,
judgment, motivation for
treatment.
Attitude/Insight/Strengths:
Client presented with a low/moderate/high level of adaptive capacity. Client reported his/her strengths as follows:
(from p.1). Client was cooperative throughout the interview and exhibited poor/fair/good judgment,
little/moderate/good insight, and a low/moderate/high level of motivation for treatment.
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Name:
Agency:
CLINICAL ASSESSMENT
ID#:
CLINICAL PRACTICUM CLASS, ANTIOCH UNIVERSITY LA
CLINICAL ASSESSMENT
Page 6 of 6
Revised 01/2012
Diagnosis
I.
Summary & Formulation: (Be sure to write from your theoretical orientation [e.g. Psychodynamic, Family Systems, CBT, Cultural
Diversity, and Feminist] and include an Affirmative Conceptualization of Client, Strengths, Coping Mechanisms, Levels of Internalized
Homophobia/Heterosexism, Potential for Therapeutic Work, Observations/Descriptions, Current Symptoms/Behaviors, and Impairments in Life
Functioning, i.e. Work, School, Home, Community, Living Arrangements, etc.)
II.
Admission Diagnostic Impression:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Principle
Secondary
Code:
Code:
Code:
Code:
Code:
Code:
Code:
Nomenclature:
Nomenclature:
Nomenclature:
Nomenclature:
Nomenclature:
Nomenclature:
Nomenclature:
Psychosocial and environmental problems that may affect diagnosis, treatment, or prognosis:
1. Primary Support Group; 2. Social Environment; 3. Educational; 4. Occupational; 5. Housing;
6. Economic; 7. Access to Health Care; 8. Interaction with Legal System;
9. Other Psychosocial/Environmental; 10. Inadequate Information.
Current GAF Score:
Signatures
Assessor’s Signature & Discipline*
Date
Co-Signature & Discipline
* Licensed MHP or unlicensed MHP with co-signature
This confidential information is provided to you in accord with
applicable Welfare and Institutions Code Section. Duplication of
this information for further disclosure is prohibited without the prior
written consent of the patient/ authorized representative to who it
pertains unless otherwise permitted by law. Destruction of this
information is required after the stated purpose of the original
request is fulfilled.
Name:
Agency:
CLINICAL ASSESSMENT
ID#:
Date