The assessment I've used for years is around five pages and it includes the following:
Identifying Information Presenting Problem(s)
Substance Abuse History
Relevant Financial Issues
Relevant Ethnic/Cultural Considerations
History of Trauma (best to just know this up front, so I ask)
*Mental Status Exam
*Suicide Risk Assessment
*Assault Risk Assessment
Diagnostic Impressions (where a diagnosis is assigned)
Clinical Summary/Impressions (overall)
Individual Strengths and Weaknesses
*Current Areas of Functional Impairment (to focus treatment)
Treatment Referrals (either to a medical doctor for a physical; a lawyer for legal aide, etc.)
Final Plan (what client agrees to)
*Release(s) of Information Obtained
Like I said, assessments differ as widely as the therapists who use them. I happen to like this assessment because it was developed to meet state requirements for someone on MediCal (which is the equivalent of Medicare for those who don't live in California). MediCal requirements are extensive, so I know my assessment is, too.
Breaking it down isn't that difficult because most of it is self-explanatory. I put a star next to those elements that might need a bit more explanation.
As you could see by the list, most of the information I gather is history, plain and simple. I have to know where a client is coming from before I can try to help them to where they want/need to go. So history gathering is extensive, and it can take more than one session to get everything down.
Psychiatric symptoms/behaviors are what I observe to be problematic during the initial interview. What symptoms of disorders are florid (very clearly exemplified)? Are they agitated? Tearful? Which symptoms does the client self-report (it can be that a client has panic attacks that I'd never see in the office, for example)? A knowledge of the Diagnostic and Statistical Manual is imperative for this type of assessment.
A mental status exam is kind of like a mini-assessment all by itself. I basically see if the person is in their right mind or not. Do they know who they are? What year it is? Who is president? What 2+2 is? Can they remember my name five minutes into our assessment after I gave it to them at the beginning? What is their speech pattern like? How are the groomed/dressed? These types of questions, if answered incorrectly, can automatically point a therapist to severe disorders like schizophrenia.
A suicide risk assessment and an assualt risk assessment are included to protect the therapist from litigation. No one would want a client to come to see them only to kill themselves hours later. So I've developed the habit of always broaching the subject of self harm and harm to others in the first session, just to see the client's reaction (are they shocked because they are offended, or because they have had suicidal thoughts?) and be able to note in my case notes for that client their response. This shows that I have acted as a reasonable therapist and protects me should I get sued (which thankfully I have never been!).
Current areas of functional impairment is just a fancy way of saying "What areas does this client struggle with the most?" How severe is the struggle? Moderate? Mild? None? Extreme? Here are the major areas I assess for:
1. Community Living
2. Community Participation
3. Community Contribution
5. Relationships with Others
6. Education and Learning
7. Physical and Emotional Health
And the release of information section is just to know who exactly I have permission to coordinate treatment with. I did a lot of school counseling, so I always had to have a release of information for the school. If you need to be in contact with a medical doctor, their name should be on a release somewhere. Having a list of all these contacts in one place is very handy.
So, this is what all I include in an assessment. This is not to be confused with intake paperwork a client fills out when they come into your office. An assessment is a document likely no client will see. Intake paperwork asks some of the same type information I've listed, and most therapists can compare the information to what the client actually tells them, looking for consistency, as well as use the intake paperwork to help fill in the assessment after the session is over (to spark their memory, etc.). It never hurts to repeat information in different places.
Join me next week as I discuss the Diagnostic and Statistical Manual-IV-TR, also known as the DSM or therapist's "bible."
Q4U: Have you or someone you know ever gone through an assessment similar to what I've described above? What might have been some areas left out of my assessment that were on yours?