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Clinical Assessment 3.0

Content type
User Generated
Subject
Psychology
School
Harvard University
Type
Homework
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© 2013. Diane R. Gehart, Ph.D. All rights reserved. www.masteringcompetencies.org
Clinical Assessment 3.0
Clinician:
N/A
Client ID #:
N/A
Primary configuration:
Individual Couple Family
Primary Language:
English Spanish Other:
List client and significant others
Adult(s)
Select Gender Age: N/A Select EthnicitySelect Relational StatusOccupation: N/A Other identifier: N/A
Select Gender Age: N/A Select EthnicitySelect Relational StatusOccupation: N/A Other identifier: N/A
Child(ren)
Identifier: Select Gender Age:N/A Select Ethnicity Grade: Select Grade Other: N/A
Identifier: Select Gender Age:N/A Select Ethnicity Grade: Select Grade Other: N/A
Identifier: Select Gender Age:N/A Select Ethnicity Grade: Select Grade Other: N/A
Identifier: Select Gender Age:N/A Select Ethnicity Grade: Select Grade Other: N/A
Others: N/A
Presenting Problem(s)
Couple concerns
Parent/child conflict
Partner violence/abuse
Divorce adjustment
Remarriage adjustment
Sexuality/intimacy concerns
Major life changes
Legal issues/probation
Other: N/A
Complete for children:
School failure/decline performance
Truancy/runaway
Fighting w/peers
Hyperactivity
Wetting/soiling clothing
Child abuse/neglect
Isolation/withdrawal
Other:
Mental Status Assessment for Identified Patient
Interpersonal
NA
Conflict Enmeshment Isolation/avoidance Harassment Other:
Mood
NA
Depressed/Sad Anxious Dysphoric Angry Irritable Manic Other:
Affect
NA
Constricted Blunt Flat Labile Incongruent Other:
Sleep
NA
Hypersomnia Insomnia Disrupted Nightmares Other:
Eating
NA
Increase Decrease Anorectic restriction Binging Purging Other:
Anxiety
NA
Chronic worry Panic Phobias Obsessions Compulsions Other:
Trauma
Symptoms
NA
Hypervigilance Flashbacks/Intrusive memories Dissociation Numbing
Avoidance efforts Other:
Psychotic
Symptoms
NA
Hallucinations Delusions Paranoia Loose associations Other:
Motor activity/
Speech
NA
Low energy Hyperactive Agitated Inattentive Impulsive Pressured speech
Slow speech Other:
Thought
NA
Poor concentration Denial Self-blame Other-blame Ruminative Tangential
Concrete Poor insight Impaired decision making Disoriented Other:
Socio-Legal
NA
Disregards rules Defiant Stealing Lying Tantrums Arrest/incarceration
Initiates fights Other:
Other Symptoms
NA
N/A
Diagnosis for Identified Patient

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© 2013. Diane R. Gehart, Ph.D. All rights reserved. www.masteringcompetencies.org
Contextual Factors considered in making diagnosis: Age Gender Race/Ethnicity Language Religion
Social class Immigration Sexual/gender orientation Cognitive ability Other:Geographic Isolation from
adequate mental health
Describe impact of identified factors on diagnosis and assessment process: N/A
DSM-5 Level 1 Cross-Cutting SymptomMeasure (optional): Elevated scores on: (free at psychiatry.org)
I Depression II Anger III Mania IV Anxiety V Somatic VI Suicide VII Psychosis VIII Sleep
IX Memory X Repetitive XI Dissociation XII Personality XIII Substance Not administered
DSM-5 Code
Diagnosis with SpecifierInclude Z/T-Codes for Psychosocial Stressors/Issues
1. F31.2
2. F60.2
3. Z62.811
4. Z56.9
5. Z65.8
1. Bipolar I Disorder, Most recent episode Manic
2. Antisocial Personality Disorder
3. History of psychological abuse by parents
4. Employment-Job loss
5. Geographic Isolation
List Specific DSM-5 Criterion Met for Diagnosis
1. Bipolar I Disorder, Most recent episode Manic
2. Antisocial Personality Disorder
3. History of psychological abuse by parents
4. Employment-Job loss
5. Geographic Isolation
Medical Considerations
Has patient been referred for psychiatric evaluation? Yes No
Has patient agreed with referral? Yes No NA
Psychometric instruments used for assessment: None Cross-cutting symptom inventories Other:Inverted Pyramid
Method
Client response to diagnosis: Agree Somewhat agree Disagree Not informed for following reason:
Current Medications (psychiatric & medical) NA
1. ; dose mg; start date:
2. ; dose mg; start date:
3. ; dose mg; start date:
4. ; dose mg; start date:
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 and Safety Assessment for Identified Patient
Suicidality
No indication/Denies
Active ideation
Passive ideation
Intent without plan
Intent with means
Ideation in past year
Attempt in past year
Family or peer history of completed
suicide
Homicidality
No indication/Denies
Active ideation
Passive ideation
Intent without means
Intent with means
Ideation in past year
Violence past year
History of assaulting others
Cruelty to animals
Alcohol Abuse
No indication/denies
Past abuse
Current; Freq/Amt: N/A
Drug Use/Abuse
No indication/denies
Past use
Current drugs:N/A
Freq/Amt: N/A
Family/sig.other use

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Clinical Assessment 3.0 Clinician: Client ID #: Primary configuration: Primary Language: N/A N/A Individual Couple Family English Spanish Other: List client and significant others Adult(s) Select Gender Age: N/A Select EthnicitySelect Relational StatusOccupation: N/A Other identifier: N/A Select Gender Age: N/A Select EthnicitySelect Relational StatusOccupation: N/A Other identifier: N/A Child(ren) Identifier: Select Gender Age:N/A Identifier: Select Gender Age:N/A Identifier: Select Gender Age:N/A Identifier: Select Gender Age:N/A Select Ethnicity Grade: Select Grade Other: N/A Select Ethnicity Grade: Select Grade Other: N/A Select Ethnicity Grade: Select Grade Other: N/A Select Ethnicity Grade: Select Grade Other: N/A Others: N/A Depression/hopelessness Anxiety/worry Anger issues Loss/grief Suicidal thoughts/attempts Sexual abuse/rape Alcohol/drug use Eating problems/disorders Job problems/unemployed Interpersonal Mood Affect Sleep Eating Anxiety Trauma Symptoms Psychotic Symptoms Motor activity/ Speech Thought Socio-Legal Other Symptoms NA NA NA NA NA NA NA NA Presenting Problem(s) Couple concerns Complete for children: Parent/child conflict School failure/decline performanc ...
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