CJUHSD CLINICAL INTERVIEW

(AUGMENT WITH CUM DATA; USE DIFFERENT COLOR INK FOR STUDENT AND PARENT)

Examiner:______________________________________________________________

IDENTIFYING INFORMATION
NAME: F:F P/C DATE:
NAME: F:F P/C DATE:

DOB: Age: Gender: Counselor: Grade:

Ethnic Background: 1Lang: Domin. Lang Glasses: N Y for _______

Best way to contact parent: Uses? N Y

PROJECTIVE/SOCIAL/ADAGES/MISC
Three Wishes:
Best/Worst:
Strengths/Weakness:
Other’s views of strengths/weaknesses
Social (best/close friends; girl/boyfriends):
Interests: Frequency:
Who are you like in your family?
I get really mad when:
I love:
I hate:
If you could wake up tomorrow w/ one thing magically changed…?
GRASS GREENER:
EARLY BIRD:
SPILT MILK:
AFTER-SCHOOL SCHED:
TECH IN ROOM: Computer Internet TV Radio Phone Game Console Handheld system Cell phone

RESIDENCE HISTORY
History of out-of-home placement: Y N
CSW: SB Riv LA OC Phone:
1 Reason for move:
2 Reason for move:
3 Reason for move:
4 Reason for move:

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 GENOGRAM

SCHOOL HISTORY
ELEMENTARY:
JR HIGH/INTERMED:
HIGH SCHOOL:

Prior Psychoeducational Assessments? UNK NO YES: _____________________________________________________________

DISABILITY: SE INCEPTION: RETENTION/SKIPPED:

“What’s hard about school for you?”

DISCIPLINE HX [H,C]: • Office Referrals Denied Hx • Suspensions Denied Hx • Expulsions Denied Hx

Details:

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 PSYCHIATRIC HISTORY
GROOMING/HYGIENE [D,P]: Shower frequency:

SPEECH [S,B]: Organized Coherent Impediment Soft Loud Hard to understand Rapid [B] Monotone [A]

THOUGHT PROCESS [P,S,H]: Organized Coherent Tangential [P,H] Thought-blocking [P] Flight of Ideas [P]

MOOD [B,D,A]: Euthymic Elevated [B] Anxious [A] Dysphoric [D] Depressed [D] Expansive [B] Mood Swing Hx [B]

AFFECT: Appropriate Inappropriate [P] Guarded Irritable [D,C] Blunted [S,P,D] Labile [P] Restricted Flat [S,P]

ENERGY [D,H]: WNL Psychomotor Agitation [D] Psychomotor Retardation [D] Energy level interferes w/ classroom functioning [H]

SLEEP [D,A,P]: ( No problems reported) Initial Insomnia [D,H,A,P] Broken Sleep [D] Terminal [D] Nightmares Night Terrors
Bedtime: Naps: Inception: Frequency:

APPETITE [D]: ( No problems reported) Increase in Appetite [D] Decrease in Appetite [D] Vomiting [A] Purging
Meals per day: Inception: Frequency:

DELUSIONS [P]: Denied Paranoid delusions ( Hx) Grandiose delusions ( Hx) Overvalued Ideas Rule Out

HALLUCINATIONS [P]: Denied Auditory hallucinations ( Hx) Visual hallucinations ( Hx) Rule Out
Noises White Noise Voices/unclear Voices Voices/command:

History of Mental/Emotional Illness in Family: ( None reported)

Maternal:
Paternal:

INPATIENT/OUTPATIENT MENTAL HEALTH HISTORY: No previous inpt tx No previous outpt tx

Outpt: Inception: Frequency: Reason:

Inpt:

THERAPIST: Phone:
PSYCHIATRIST: Phone:

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 MEDICAL HISTORY
Current Health Problems: ( None reported)

History of Head Injuries Fainting Seizures Hospitalizations Broken Bones Surgery

Current and Past Medications (psychotropic & other, including over-the-counter; include dosage if known):
Past: ( None)
Current: ( None)

SUBSTANCE PROBLEMS (describe use)

Nicotine ( denied) Exper. Hx Sig. Hx Current
Alcohol ( denied) Exper. Hx Sig. Hx Current
Drugs ( denied) Exper. Hx Sig. Hx Current

DEVELOPMENTAL HISTORY/ MILESTONES No unusual prenatal events Perinatal development WNL

Maternal drug use [A]: Birthweight [A]:

EMPLOYMENT: VOCATION/POST-GRAD PLANS:

LEGAL HISTORY
ARRESTS [C]: ( None reported)

PROBATION [C]: Formal Informal Phone:

RISK ASSESSMENT
Allergies and Adverse Reactions to Medications: ( No allergies/adverse reactions to medicines or other substances reported)

Hx of Abuse and/or Victimization: ( Denied)

Suicidality [D,P]: ( Denied) Ideation Intent Means Plan Attempts Gestures Cutting

If attempt hx exists/clear expectation of death? No Yes:

Homicidality [C,P]: ( Denied) Ideation Intent Means Plan Attempts Gestures Person at risk:_______________________

• Clin sig firesetting Denied Hx • physical aggression Denied Hx • cruelty to animals Denied Hx • AWOL overnight Denied Hx

Insight: Good Average Poor in general Issue-specific:_________________________________________________

Judgment: Good Average Poor in general Issue-specific:_________________________________________________

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 DIAGNOSTIC CONSIDERATIONS
Detailed, documented cumulative record review
Clinical observation
Student interview data
Parent interview data
Collateral interview data
Rating scale data (e.g. BASC-2, MMPI-A, Conners, Hamiltons)
Previous assessment data
Consult

[H] RULE OUT ADHD SX

• CUM review is critical!!
• Family history
• ADHD diagnostic checklist

[B] RULE OUT BIPOLAR SX

• Intense, irrational irritability; look for grandiose tones
• Family history
• Mood Disorder Questionnaire (MDQ)
• Bipolar diagnostic checklist

[D] RULE OUT DEPRESSIVE SX

• Family history
• Hamilton Depression Rating Scale (HAM-D)
• Depressive symptoms checklist

[A] RULE OUT ANXIETY SX

• Not uncommon to manifest in difficulty mornings; lates/absences in Per 1/2.
• Somatic complaints w/ no clear physical etiology (e.g. stomachaches, headaches)
• Family history
• Hamilton Anxiety Rating Scale (HAM-A)
• Panic symptom checklist

[P] RULE OUT PSYCHOSIS SX

• Must have hallucinations, delusions or loss or reality-testing
• Is sleep problems, clarify exact nature
• Family history

[C] RULE OUT CONDUCT SX

• Violation of others rights
• Legal history
• Gang/crew affiliation
• Family history

[S] RULE OUT ASPERGERS SX

• Communicates verbally fine, but impaired non-verbal and odd
• Family history

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 AUTISM ADDENDUM
STUDENT: DATE:

CONTACT: MODE: DATE:

CONTACT: MODE: DATE:

Language Nonverbal

Self-Stimulating Behavior (stimming) None currently History Current

Behavior Concerns None currently History Current

Aggressive Behavior None currently History Current

Self-Harming Behavior None currently History Current

Triggers None currently History Current

Self-Care Issues None currently History Current

Effective Intervention/Strategies

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