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UNM DEPARTMENT OF PSYCHOLOGY CLINIC
INTAKE OUTLINE AND REPORT
LEVEL OF EDUCATION
DATE OF BIRTH:
IDENTIFYING INFORMATION AND REFERRAL STATEMENT
1. Include description of client’s (individual, couple, family,c.) age, occupation,
marital status and any other significant identifying information such as
previous treatment at the Psychology Clinic (e.g., Mrs. M. is a 40 year old, single
parent of three children, who works as a bookkeeper. Had previously been seen
at the Therapeutic Clinic for one session. (See Intake on file 1/07/80).
2. Indicate the referral source, such as self-referral, referral by a physician, or
social agency, and if there was a specific reason for the referral (e.g., Mrs. M.
was referred to the Therapeutic Clinic by the Family Resource Center because
of alleged neglect of her children).
State briefly what is the most distressing at this time and use the client’s own words
whenever possible using quotes. Indicate what kind of treatment they desire or
expect, and what results they hope for (e.g., Mrs. M. would want her boyfriend
involved in treatment, though he reportedly refuses to come in; Mrs. M. hopes to “get
along better with him” and “take better care of my children.”).
HISTORY OF PRESENTING COMPLAINT:
Describe in chronological order (and with dates) the onset and development of the
presenting complaint and how it is manifested.
(a) Onset – when the problem began to affect or interfere with the client’s daily
living or became manifest to those around him.
(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.)
and severity of stressors.
(c) Previous conditions, psychiatric hospitalizations and/or treatment which were
similar to or the same as the presenting complaint (this information is often
asked on insurance claim forms).
Brief and mentioned if applicable. Note special medical problems present
and any substance abuse. List current medications.
(Only if applicable) If personal history is not utilized,
significant events or changes may be documented in
Therapist Notes, Transfer Summary, or Closing Summary,
This should briefly include any relevant occurrence (developed chronologically) and
can use the following headings as a guide:
(a) Birth and Infancy: Were there any difficulties or special circumstances
(medical, adoption, frequent moves, etc.)
(b) Childhood: Overall adjustment and relationships to peers as well as academic
performance (e.g., did above-average work in school and reported positive peer
(c) Adolescence: Further development including any behavioral changes, family
circumstances, peer adjustment, education, and relationships with the opposite
(d) History up to time of presenting complaint including vocational information,
dating/sexual experiences, and marital relationship(s) if applicable. Note
present living arrangement and significant socio-economic circumstances or
CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:
Include (1) pertinent dynamic factors in the development of the presenting
complaint, taking into account psychological aspects of the client’s life (e.g., family;
employment, etc.), (2) appraisal of insight and motivation for treatment, and (3)
level of functioning or impairment, including the client’s own strengths and
Areas of functioning and/or impairment should focus on: (1) symptomatology, (2)
productivity (employment; activities of daily living), (3) capacity for pleasurable
experiences (hobbies; entertainment), (4) interpersonal relationships, (5) capacity to
handle ordinary conflicts and stresses. Assess and record whether impairment or
reactions in these areas are mild, moderate or severe.
Note any significant information which might mean the client is “at risk” (suicidal
ideation, homicidal ideation, etc.).
[Where applicable briefly note and/or assess defenses, affect, behavior, personality
style, traits, and patterns. In evaluating the client, take into consideration the
mental status examination.]
According to DSM V, or (2) Dynamic formulation with clinical features, or (3)
Reason for contact with the agency.
CASE FORMULATION & TREATMENT PLANNING RECOMMENDATIONS:
Case formulation is the bridge between clinical assessment and treatment
planning. (See page 415 textbook). You attempt to synthesize all that has been
learned about the patient’s past, so as to point the way to a better future
Several reasons for preparing a formulation: (1) To focus your thinking about the
patent, (2) To summarize the logic behind your diagnoses, (3) To identify future
needs for information and treatment, and (4) To present a brief summary of the
State type of treatment utilized (e.g., crisis, insight-oriented, supportive,
behavioral, psychotherapy, etc.), the treatment modality (e.g., estimated length of
treatment, changes in modality, etc.). Include designation of the primary
therapist(s) (e.g., Will be seen by the undersigned and Ms. M, in group therapy).
(a) Treatment focus and/or goals with specific reference to the client’s
“reason for seeking treatment.”
(e.g., Initial treatment recommendation is individual psychotherapy on a once weekly
basis. Therapy will focus on Mrs. M.’s presenting concerns around her relationship
with boyfriend and child management issues. Couple treatment is possible in the
future, but boyfriend presently refuses to attend sessions. Will work on symptom
relief (early morning wakening) and increasing her ability for pleasurable experiences,
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