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  • Name: Case #: Date: Time: DOB/Age: Sex: Race: Marital Status: Employment/Education Level

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    meganmstodard
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    This document contains an initial diagnostic assessment and evaluation for a client. It collects information on the client's presenting problem, history of psychiatric and substance abuse treatment, family history, developmental history, relationships, victimization, medical issues, living situation, legal issues, education, and cultural factors. Based on the information gathered, the evaluator provides a provisional diagnosis and treatment plan consisting of 8 sessions of individual therapy.

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    Intake Outline

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    This document contains an initial diagnostic assessment and evaluation for a client. It collects information on the client's presenting problem, history of psychiatric and substance abuse treatment, family history, developmental history, relationships, victimization, medical issues, living situation, legal issues, education, and cultural factors. Based on the information gathered, the evaluator provides a provisional diagnosis and treatment plan consisting of 8 sessions of individual therapy.

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    6 views3 pages

    Name: Case #: Date: Time: DOB/Age: Sex: Race: Marital Status: Employment/Education Level

    Uploaded by

    meganmstodard
    This document contains an initial diagnostic assessment and evaluation for a client. It collects information on the client's presenting problem, history of psychiatric and substance abuse treatment, family history, developmental history, relationships, victimization, medical issues, living situation, legal issues, education, and cultural factors. Based on the information gathered, the evaluator provides a provisional diagnosis and treatment plan consisting of 8 sessions of individual therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    DIAGNOSTIC ASSESSMENT/INITIAL EVALUATION IDENTIFYING DATA Name: Case #: Date: Time: DOB/Age: REFERRAL BEHAVIORAL OBSERVATIONS

    Appearance, dress, hygiene, gait, eye contact, Unusual movements/gestures, apparent stated age, mood, affect, speech, thought process, perceptual abnormalities, insight, judgment, reliability, suicidal/homicidal ideation, Intellect, orientation.

    Sex: Race: Marital Status: Employment/Education Level:

    PRESENTING PROBLEM

    CLIENT HISTORY OF PSYCHIATRIC TREATMENT AND/OR SUBSTANCE ABUSE TREATMENT

    FAMILY HISTORY OF PSYCHIATRIC TREATMENT AND/OR SUBSTANCE ABUSE TREATMENT

    DEVELOPMENTAL AND FAMILY HISTORY

    RELATIONSHIP

    VICTIMIZATION

    SUBSTANCE ABUSE/ADDICTION PROBLEMS

    MEDICAL PROBLEMS AND MEDICATION

    CURRENT LIVING SITUATION

    LEGAL ISSUES

    ACADEMIC/VOCATIONAL/CAREER BACKGROUND

    XV. CULTURAL ISSUES No cultural issues were discussed at this time. XVI.INTERPRETIVE SUMMARY XVII. PROVISIONAL DIAGNOSIS Axis I: Axis II: Axis III: Axis IV: Axis V: Current GAF XVIII.DISPOSITION/PLAN I will meet with the client for 8 sessions of individual therapy. The next session is scheduled for next week.

    _______________________________________Megan M. Stodard, Ph.D. Post- Doctoral Psychology Fellow _______________________________________Karen Lake, Ph.D. Licensed Clinical Psychologist

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