MCA BioPsychoSocial Diagnostic Intake and Case Formulation Where space is insufficient, use an asterisk and write the information on the back of any page.

I. Demographic Information.

Patient: __________________________________ Gender: Male Female Date of Interview: _____/_____/_____

Date of Birth: _____ /_____ /_____ Chronological Age: _____ Social Security #: _____-_____-_____

Purpose of this intake: ❑ New client evaluation ❑ Readmission; previous intake on: _______________________________________

❑ Consultation; copy to be sent to: ___________________________________________________________________

❑ Reevaluation or review ❑ Other purpose(s): _____________________________________________________

II. Primary Symptoms.

Checklist Adult Concerns.Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. ❑ I have no problem or concern bringing me here ❑ Abuse (Physical, emotional, neglect, cruelty to animals)

❑ Aggression, violence ❑ Alcohol use

❑ Anger, hostility, arguing, irritability ❑ Anxiety, nervousness

❑ Attention, concentration, distractibility ❑ Career concerns, goals, and choices

❑ Childhood issues (your own childhood) ❑ Codependence

❑ Confusion ❑ Compulsions

❑ Custody of children ❑ Decision making, indecision, mixed feelings, putting off decisions

❑ Delusions (false ideas) ❑ Dependence

❑ Depression, low mood, sadness, crying ❑ Divorce, separation

❑ Drug abuse ❑ Eating problems—overeating, undereating, appetite, vomiting

❑ Emptiness ❑ Failure

❑ Fatigue, tiredness, low energy ❑ Fears, phobias

❑ Financial troubles, impulsive spending ❑ Friendships

❑ Gambling ❑ Grieving, mourning, deaths, losses, divorce

❑ Guilt ❑ Headaches, other kinds of pains

❑ Health, illness, medical, physical concerns ❑ Housework—quality, schedules, sharing duties

❑ Inferiority feelings ❑ Interpersonal conflicts

❑ Impulsiveness, loss of control, outbursts ❑ Irresponsibility

❑ Judgment problems, risk taking ❑ Legal matters, charges, suits

Confidential-For Professional Use Only: This report is strictly confidential material and is only for the information of the person to whom McCarthy Counseling Associates, PA & The Center for Psychophysiological Assessment and Treatment addresses it. No responsibility can be accepted if it is made available to any other person, INCLUDING THE PATIENT. Any duplication, transmittal, re-disclosure or retransfer of these records is expressly prohibited. Such disclosure may be subject to civil liability.

❑ Loneliness ❑ Marital conflict

Memory problems❑ ❑ Menstrual problems, PMS, menopause

❑ Mood swings ❑ Motivation, laziness

❑ Nervousness, tension ❑ Obsessions, compulsions (thoughts, actions repeat)

❑ Oversensitivity to rejection ❑ Pain, chronic

❑ Panic or anxiety attacks ❑ Parenting, child management, single parenthood

❑ Perfectionism ❑ Pessimism

❑ Procrastination, work inhibitions, laziness ❑ Relationship problems (friends, relatives, work)

❑ School problems (see also “Career concerns ...”) ❑ Self-centeredness

❑ Self-esteem ❑ Self-neglect, poor self-care

❑ Sexual issues, dysfunctions, conflicts ❑ Shyness, oversensitivity to criticism

❑ Sleep problems—too much, too little, insomnia, nightmares ❑ Smoking and tobacco use

❑ Spiritual, religious, moral, ethical issues ❑ Stress, trouble relaxation, tension

❑ Suspiciousness, distrust ❑ Suicidal thoughts

❑ Temper problems, self-control, low frustration tolerance ❑ Thought disorganization and confusion

❑ Threats, violence ❑ Weight and diet issues

❑ Withdrawal, isolating ❑ Work problems, workaholism, can’t keep a job

❑ Other concerns or issues: ______________________________________________________________________

Checklist of Child, Adolescent Concerns.Many concerns can apply to both children and adults. Review this checklist, which contains concerns (as well as positive traits) that apply mostly to children, and mark any items that describe your patient. Feel free to add any others at the end under “Any other characteristics.”

❑ Affectionate ❑ Argues, “talks back,” smart-alecky, defiant

Argues, “talks back,” smart-alecky,

defiant

❑ Bullies/intimidates, inflicts on others, bossy, provokes ❑ Cheats

❑ Cruel to animals ❑ Concern for others

❑ Conflicts with parents ❑ Complains

❑ Cries easily, feelings are easily hurt ❑ Dawdles, procrastinates, wastes time

❑ Difficulties with parent’s paramour/marriage/family ❑ Dependent, immature

❑ Developmental delays ❑ Disrupts family activities

❑ Disobedient, uncooperative, noncompliant, dislikes rules ❑ Distractible, inattentive, daydreams, slow to respond

❑ Dropping out of school ❑ Drug or alcohol use

❑ Eating—poor manners, increase, decrease appetite, odd ❑ Exercise problems

❑ Extracurricular activities interfere with academics ❑ Failure in school

❑ Fearful ❑ Fighting, violent, aggressive, threatens, destructive

❑ Fire setting ❑ Friendly, outgoing, social

❑ Hypochondriac, always complains of feeling sick ❑ Immature, “clowns around,” only younger playmates

❑ Imaginary playmates, fantasy ❑ Independent

❑ Interrupts, talks out, yells ❑ Lacks organization, unprepared

❑ Learning disability ❑ Legal problems (vandalism, stealing, fighting)

❑ Likes to be alone, withdraws, and isolates ❑ Lying

❑ Low frustration tolerance, irritability ❑ Mental retardation

❑ Moody ❑ Mute, refuses to speak

❑ Nail biting ❑ Nervous

❑ Nightmares ❑ Need for high degree of supervision

❑ Obedient ❑ Obesity

❑ Overactive, restless, hyperactive, restlessness, fidgety ❑ Oppositional, resists, does not comply,

negativism

❑ Prejudiced, bigoted, insulting, name calling, intolerant ❑ Pouts

❑ Recent move, new school, loss of friends ❑ Relationships brothers/sisters/ friends/peers poor

❑ Responsible ❑ Rocking or other repetitive movements

❑ Runs away ❑ Sad, unhappy

❑ Self-harm—biting, hitting, head banging, scratch, cutting ❑ Speech difficulties

❑ Sexual—preoccupation, public masturbation, inappropriate ❑ Shy, timid

❑ Stubborn ❑ Suicide talk or attempt

❑ Swearing, blasphemes, bathroom language, foul language ❑ Temper tantrums, rages

❑ Thumb sucking, finger sucking, hair chewing ❑ Tics—involuntary movements, noises, words

❑ Teased, picked on, victimized, bullied ❑ Truant, school avoiding

❑ Underactive, slow-moving or slow-responding, lethargic ❑ Uncoordinated, accident-prone

❑ Wetting or soiling the bed or clothes ❑ Work problems, workaholism, can’t keep a job

III. Diagnoses—Current best formulation (Admitting diagnosis) Code #: ❑ DSM-IV or ❑ ICD?

Axis I: __________________________________ ❑ (R\O) ______________________________________ ❑ (R\O)

__________________________________ ❑ (R\O) ______________________________________ ❑ (R\O)

_________________________________ ❑ (R\O) ______________________________________ ❑ (R\O)

Axis II: __________________________________ ❑ (R\O) ______________________________________ ❑ (R\O)

__________________________________ ❑ (R\O) ______________________________________ ❑ (R\O)

❑ (R\O) “Rule-outs” (other possible diagnoses to be evaluated over time)

V Codes—Other problems that may be a focus of clinical attention: __________________________________________

Axis III: Significant and relevant medical conditions, including allergies and drug sensitivities:

❑ Allergies ❑ Carpal Tunnel ❑ Epilepsy\Seizures ❑ Migraines ❑ Physical disability❑ Anemia ❑ Cirrhosis ❑ Heart disease ❑ Multiple sclerosis ❑ Psoriasis❑ Arteriosclerosis ❑ Chronic pain ❑ Hepatitis ❑ Muscular dystrophy ❑ STDs❑ Arthritis ❑ Cystic fibrosis ❑ Hypercholesterolemia ❑ None ❑ Stroke❑ Asthma ❑ Deaf\Impaired ❑ Hyperlipidemia ❑ Obesity ❑ Tinnitus❑ Birth defects ❑ Diabetes ❑ Hypertension ❑ Osteoporosis ❑ Ulcers❑ Blind\Impaired ❑ Digestive disorder ❑ Hyperthyroid ❑ Cancer ❑ Ear infections❑ Infertility ❑ Parkinson's disease ❑ Other: ❑ Other : ❑ Other :

Axis IV: Psychosocial and environmental problems in last year; overall severity rating: ___________________❑ Problems with primary support group ❑ Problems related to the social environment

❑ Educational problems ❑ Occupational problems❑ Housing problems ❑ Economic problems ❑ Problems with access to health care services ❑ Problems related to legal system/crime

❑ Other psychosocial and environmental problems (specify): _____________________________________________

Level of Fun ctioning GAF rating

1. School/work functioning: _________________________________________________________________________

2. Intimate relationship/marriage: _____________________________________________________________________

3. Family/children: ________________________________________________________________________________

4. Social relationships: _____________________________________________________________________________

5. Psychological/personal functioning: _________________________________________________________________

6. Other areas: ___________________________________________________________________________________

Axis V: Global Assessment of Functioning (GAF) Rating: Currently: _________ Highest in past year: _________

Present Level of functioning/limitations/impairment (Describe specific impairments at left, and rate degree of functional impairment at right with GAF number [100 = none, 70 = little, 30 = significant, 10 = incapacitated] or use descriptors):

Global Assessment of Functioning Scale (GAF): Current: ____ Highest in past year: ____

90-100 Superior function 81-90 Minimal symptoms 71-80 Mild/transient symptoms 61-70 Mild symptoms 51-

60 Moderate symptoms 41-50 Serious symptoms 40 Impaired reality testing 21-30 Inability to function 11-20

Some danger 01-10 Serious danger hurting self/others

Social and Occupational Assessment Scale (SOFAS): Current: ___ Highest in past year: ____

91-100 Superior function 81-90 Good Functioning 71-80 Slight impairment 61-70 Some difficulty 51-60

Moderate Difficulty 41-50 Serious impairment 31-40 Major impairment 21-30 Inability to function 11-20 Fails

ADL skills 01-10 Persistent inability to maintain personal hygiene

Global Assessment of Relational Functioning Scale (GARF): Current: ___ Highest in past year: ___

81-100 Functioning satisfactorily 61-80 Somewhat unsatisfactory 41-60 Dysfunctional

21-40 Seriously dysfunctional 1-20 Seriously dysfunctional

Treatment/medication (regimen) Provider Status 1.

2.

3.

4.

IV. Family of Origin History.

Parent Name Age Status Education Occupation Personal Adjustment\Health(M)(F)(SM)(SF)(SM)(SF)

Parents are: ❑ Married ❑ Single ❑ Separated ❑ Divorced 

Describe nature of parent’s relationship with each other as well as patient’s relationship with parents (past and current):

❑ No excessive parental arguing\conflict\witnessing trauma reported

Sibling(s) Age Relationship Education Occupation Personal History

Clinician comments:

❑ No excessive sibling arguing\conflict reported

Intimate Relationships Age Education Occupation Seriousness Personal Adjustment\Health

Clinician comments:

❑ No excessive relationship difficulty\arguing\conflict reported

Children\Stepchildren Age Relationship Grade Personal Adjustment\Health

Relevant Custody issues: Parental alienation issues❑

Clinician comments:

❑ No excessive arguing\conflict with children\stepchildren reported

  Family History Substance Abuse

Mental Disorder

Suicide Violence Learning Problems

Other

MotherFatherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherPaternal: aunt uncleMaternal: aunt uncle

Clinician comments: 

❑ Denied family history in accordance with above chart

V. Sexual Orientation.Sexual Orientation: ❑ Homosexual ❑ Heterosexual ❑ Bisexual

Sexual activity level: ❑ Active ❑ Abstinent (Give Duration\Reason):

Age first sexual experience (Give circumstances\Reaction): ____________________________

Sexual Disorder: ❑ Sexual desire disorder ❑ Sexual female arousal disorder ❑ Erectile dysfunction ❑ Premature ejaculation ❑ Orgasmic disorder ❑

Dyspareunia❑ Vaginismus ❑ Paraphilic disorder ❑ Pornography use❑ Other: ____________________________________________________________________

Clinician comments:

VI. Social History.

Composition of Social Support Network: ❑ Peers ❑ Friends ❑ Acquaintances

Quality of support network: ❑ Adequate ❑ Limited ❑ Deficient ❑ Isolative ❑ Extroverted

Description: _________________________________________-

_____________________________________________

 Gang involvement: ❑ Yes ❑ No Describe: _________________________________________________ Authority figures: ❑ Conforming ❑ Oppositional ❑ Rebellious ❑ EnmeshedHobbies\Interests: ❑ Yes ❑ No Type: ____________________________________________________

Clinician comments:

VII. Spiritual Orientation.Raised: ❑ Catholic ❑ Jewish ❑ Moslem ❑ Buddhism

❑ Atheist ❑ Agnostic ❑ Protestant (Denomination):

❑ Other: ______________________________________________________________

Adult: ❑ Catholic ❑ Jewish ❑ Moslem ❑ Buddhism

❑ Atheist ❑ Agnostic ❑ Protestant (Denomination):

❑ Other: ______________________________________________________________

Clinician comments:

VIII. MEDICAL HISTORY. Overall health:   ❑ Excellent ❑ Good ❑ Fair ❑ Fragile ❑ Complex ❑ Poor Date of last physical examination: / / Result(s) of exam: ❑ Positive ❑ Negative

Primary Care Physician (PCP): ________________________________________________________________

PCP’s office address: _______________________________________________________________________

Specialist: ________________________________________________________________________________

Specialist’s office address: ___________________________________________________________________

Medication History. ❑ Did not report present use of psychotropic medication(s)

Current Drug(s) Does\Frequency

Benefit\Side Effects

Prescribed By

When Prescribed? Refill Scheduled

Past Psychotropic Medications ❑ Did not report prior use of psychotropic medication(s)

Drug Name Does\Frequency

Benefit\Side Effects

Prescribed By

When Prescribed? Refill Scheduled

Other (Non-psychiatric, alternative medications) ❑ Did not report use of other medication(s)

Drug Name Does\Frequency

Benefit\Side Effects

Prescribed By

When Prescribed? Refill Scheduled

Medication allergies or adverse reactions ❑ Did not report allergic, adverse reaction(s)

Drug Name Does\Frequency

Benefit\Side Effects

Prescribed By

When Prescribed? Refill Scheduled

Does patient follow medication regimen? ❑ Yes ❑ No Explain: _____________________________

Advanced Medical Tests.❑ MRI ❑ CT Scan ❑ GI series ❑ qEEG\EEG

❑ Other: __________________________________ ❑ No advanced medical tests reported

Clinician comments:

  Cardiovascular disorders. ❑ Heart disease ❑ Heart murmur ❑ Hypertension ❑ Hypotension ❑ Stroke❑ Panic attacks ❑ Menstruation ❑ Hypercholesterolemia ❑ Migraine headaches: ❑ Moderate (<4 hrs.) ❑ Severe (2-6 hrs.) ❑ Severe refractory (6-72 hrs.) ❑ Angioplasty ❑ Bypass surgery ❑ Fainting\syncope ❑ No cardiovascular symptoms reported Clinician comments:    Respiratory.❑ Chronic cough ❑ Sore throat ❑ Bronchitis ❑ COPD ❑ Pneumonia ❑ Lung Cancer ❑ Throat cancer No respiratory problems reported ❑

Clinician comments:

Endocrine\Metabolic.Diabetes: ❑ Type I ❑ Type II ❑ Hyperthyroidism ❑ Hypothyroidism

❑ Other: _________________________________________ ❑ No endocrine\metabolic problems reported

Clinician comments:

Genito-Urinary\Reproductive.❑ Amenorrhea ❑ Urinary incontinence ❑ Postpartum depression Pregnancy problems❑❑ Menopause ❑ Prostate problems ❑ UTIs ❑ Pelvic pain❑ Penile discharge Other: ___________❑ No genito-urinary problems reported ❑

Clinician comments:

Sleep Disturbances.❑ Sudden onset insomnia ❑ Staying asleep ❑ Waking up early ❑ Sleep apnea❑ Hypersomnia ❑ Other: ___________ ❑ No sleep problems reported

Clinician comments:  

Neuromuscular Problems. Tension❑ headaches ❑ Soft tissue injury ❑ Tempromandibular disorder

❑ Broken bone ❑ Arthritis❑ TMJ

❑ Other: _____________________________________________ ❑ No neuromuscular problems reported

Fibromyalgia Criteria (American College of Rheumatology for Classification: 1990 Criteria).

❑ Widespread pain and profound fatigue ❑ Morning stiffness ❑ Sleep disturbance

Accompanying rheumatoid disease and other auto-immune disease ❑ ❑ 11 of 18 “tender” points

 

Chronic fatigue.❑ Severe chronic fatigue (Persisted 6 months or longer excluding secondary symptoms to other illnesses❑ < 4 or more of following symptoms (Cannot predate fatigue):❑ Sore throat ❑ Tender lymph nodes ❑ Muscle pain ❑ Unrefreshing sleep ❑ Headaches of new type, pattern, severity ❑ Post-exertional malaise lasting > 24 hours ❑ Physically, socially, professionally (50% reduction in premorbid level of functioning)

Multiple joint pain without swelling or tenderness❑

Clinician comments:

Dermatological\Skin.❑ Psoriasis ❑ Hair loss ❑ Itching ❑ Rashes ❑ Acne❑ Other: ___________________ ❑ No dermatological problems reported

Clinician comments:  

Gastrointestinal Disorders.❑ Ulcer: ❑ Peptic ❑ Duodenal ❑ Gastroesophageal reflux Colitis❑ ❑ Irritable bowel syndrome ❑ Crohn’s disease ❑ Constipation\Diarrhea

Colon\rectal cancer ❑ ❑ Other: __________ ❑ No gastrointestinal problems reported

Clinician comments:

 Neuroimmune Diseases.❑ Cancer ❑ Senility ❑ Seasonal allergies ❑ Multiple sclerosis❑ Mononucleosis ❑ Tremors ❑ Dizziness\Vertigo ❑ Dementia❑ Myasthenia gravis ❑ Parkinson’s ❑ Other: _______________ ❑ No neuroimmmune problems reported

Clinician comments:

Vision Problems.

❑Scotopic Sensitivity Syndrome❑ Cataracts\Glaucoma ❑ Macular degeneration

❑ Wears eyeglasses ❑ Wears contacts ❑ Blind\Blurring

❑ Flashing lights ❑ Floaters\Halo ❑ Double vision

❑ Other: ________________________________ ❑ No vision problems reported

Clinician comment:

Hearing.❑ Hearing loss: ❑ Left ear ❑ Right ear ❑ Deaf ❑ Hearing aid❑ Ear pain ❑ Tinnitus ❑ Vertigo ❑ Menniere’s disease❑ Ear infection ❑ Other: __________ ❑ No hearing problems reported

Clinician comment:

Speech. ❑ Stutter Stammer❑ L❑ isp ❑ Hoarseness

❑ Other: ❑ No speech problems reported

Clinician comment:

Head Injury and Seizure Disorders.

❑ Traumatic brain injury ❑ Closed head injury ❑ Concussion ❑ Contussion❑ Grand mal seizures ❑ Partial\Partial complex ❑ Petit mal ❑ Temporal lobe ❑ Other: ___________________________________________ ❑ No head injury, seizure reported

 

Clinician comment:

Eating Disorders\Appetite Impairment.❑ Anorexia nervosa: ❑ Restricting type ❑ Binge eating\purging type❑ Bulimia nervosa: ❑ Purging type ❑ Non-purging type❑ Morbid obesity ❑ Eating disorder NOS Sudden change:❑ ❑ Gain ____ lbs. ❑ Loss: ____ ❑ Other: _______________ ❑ No eating\appetite problems reported

Clinician comments:

Trauma-Related Symptoms.❑ Flashbacks (Type: ________________________) ❑ Nightmares (Type: ________________________)❑ Miscarriage(s): #: ___ Age(s): ___, ___, ___ ❑ Abortion(s): #: ___ Age(s): ___, ___, ___❑ Accident(s): ____________________________ ❑ Combat experience❑ Other: _________________________________ ❑ No trauma-related symptoms reported

 Clinician comments:

Chronic pain. Details (Etiology, chronicity): _______________________________________________________________________❑ Pseudoaddiction ❑ Other: _______________________________ ❑ No chronic pain problems reported

Clinician comments:

Verbal and Numerical Pain rating Scales (Adults) Subjective Units of Differentiation Scale 0-100 (SUDS): Initial: Present: Best day: Worst day:

Verbal and Numerical Pain rating Scales (Children)

Riley Infant Pain Scale Assessment Tool (Infants).

 Behavior Scoring0 1 2 3

Facial Neutral\smiling Frowning\grimacing Clenched teeth Full cry expression

Body Movement Calm, relaxed Restless/fidgeting Moderate agitation or moderate mobility

Thrashing, flailing, incessant agitation, or strong voluntary immobility

Sleep Sleeping quietly with easy respirations

Restless while asleep Sleeps intermittently (sleep/awake)

Sleeping for prolonged periods of time interrupted by jerky movements or unable to sleep

Verbal/vocal No cry Whimpering, complaining

Pain crying Screaming, high pitched voice

Consolability Neutral Easy to console Not easy to console InconsolableResponse to Movement or Touch

Moves easily Winces when touched/moved

Cries out when moved/touched

High-pitched cry or scream when touched or moved

IX. Medical Operations\Hospitalizations.Type of operation Reason for operation Outcome of surgical procedure

1.2.3.

❑ No medical operations\hospitalizations reported

Clinician comments:

X. Prior Psychiatric Diagnosis\Treatment Experiences. Clinician\Hospital Length of Treatment Reason Therapeutic benefit(s)

1.2.3.❑ Patient did not report prior psychiatric history\treatment experiences

Clinician comments:

XI. Suicidal and Homicidal Ideation, Plan, Intent.

Self-cutting\mutilation (Stress relief):  ❑ Yes ❑ No ❑ No self-mutilation reportedDescription of type, frequency, duration:

Suicide: ❑ Ideator ❑ Gesturer ❑ Attempter ❑ No suicidal ideation, plan or attempt reported Description of type, frequency, duration:

If adolescent ideator, crucial factors: ❑ Substance abuse ❑ Isolation, rejection ❑ Victim bullying ❑ Acculturation issues ❑ Academic performance ❑ Family discord ❑ Impulsivity, firearms ❑ Conduct disorder ❑ Other: _______________________________________________________________________________________

Clinician comments (Description):

If adult ideator, crucial factors: ❑ Relationship ❑ Health ❑ Self-esteem ❑ Financial security❑ Social definition ❑ Occupational definition ❑ Other: ___________________________________ What did you do?Goal of intended suicidal act:Time\energy devoted planning suicide: What was going on with you at the time?Sense calm, tranquility, renewed energy:  Clinician comments (Description):

If attempter, crucial factors: ❑ Cutting ❑ Shooting ❑ Hanging ❑ Gas ❑ Overdose❑ Other: _____________________________________________________________________________________ ❑ No prior suicidal attempts reportedWhat did you do?What was going on with you at the time? Why are you still alive?Subsequent treatment for suicidal behavior:

Clinician comments (Description):

Homicide.❑ Ideation ❑ Plan ❑ Intent ❑ Assault ❑ No ideation, plan or assault reported If ideator, answer the following questions: What exactly did you do?Goal of intended homicidal act:Time\energy devoted planning homicide: What was going on with you at the time?Sense calm, tranquility, renewed energy:

Clinician comments (Description):

If attempter, answer the following questions:What exactly did you do?What was going on with you at the time? Why is the victim still alive?Subsequent treatment for homicidal behavior:

 Clinician’s comments:

 XII. Substance Abuse.❑ Alcohol ❑ Amphetamines ❑ Barbiturates ❑ Caffeine

Cocaine❑ ❑ Hallucinogens ❑ Inhalants ❑ Marihuana❑ Methadone ❑ Opiates ❑ Over-the-counter ❑ Rx medications ❑ Sedatives ❑ Stimulants ❑ Tobacco ❑ Tranquilizers❑ Other: _________

Substance Age 1st

UseAmount\Frequency Duration

of UseDate

Last UsePeriod

Heaviest UseAmount Used Last

24 hours

History of: ❑ Withdrawal ❑ DTs ❑ Blackouts (Loss of time), seizures, etc.What happens when you stop drinking or using drugs?

What is your longest period of sobriety?

Clinician comments:

Did not report substance experimentation, abuse, dependence❑

XIII. Educational History.Level of education: ❑ Grammar school ❑ Junior high school ❑ High school

❑ College ❑ Technical-trade ❑ Professional\graduate❑ Other:

Preschool educational situations attended: ❑ Day care ❑ Pre-school ❑ KindergartenAge started 1st grade: ❑ 5 years old ❑ 6 years old ❑ Other: _____________________________Attitudinal orientation toward school: ❑ Positive ❑ Neutral ❑ Negative Classroom placement: ❑ Honors ❑ Regular ❑ Special education (Type):

❑ Homeschooling ❑ Repeated grade(s): _______ Age(s): __________________ ❑ Performance\achievement awards (Type): ________________________________________

Educational status:   ❑ Learning disabled ❑ Emotionally disturbed ❑ Hearing impaired❑ Mental retardation ❑ Visually impaired ❑ Orthopedically impaired ❑ Other health impaired Behavioral adjustment: ❑ Adaptive ❑ Behavior problems ❑ Oppositional ❑ Defiant

❑ Argumentative ❑ Aggressive ❑ Suspended ❑ Expelled No educational problems reported❑

Clinician comments:

 

XIV. Occupational History.Employment status: ❑ Employed full-time ❑ Employed part-time ❑ Permanent medical disability ❑ Temporary medical disability ❑ Unemployed (Reason: ___________________________)Occupation if employed: Gross monthly income:Family support: ❑ Joint head household ❑ Male head household ❑ Female head household

❑ None-head of household ❑ Size of household: ____

Living arrangements: ❑ Lives alone ❑ Lives with spouse\significant other ❑ Homeless ❑ Lives with friend, roommate ❑ Lives with family ❑ Lives with unrelated person(s)❑ Other: ____________________________________________________________________

Does patient have a caregiver? ❑ Yes ❑ No If so, whom?Job satisfaction\performance: ❑ Satisfied, enjoys nature work ❑ Dissatisfied, dislikes nature work ❑ Disciplined

❑ Suspended ❑ Terminated ❑ Frustrated aspirations❑ No job-related problems reported

Clinician comments: 

XV. Military History.Served in military: ❑ Yes ❑ NoBranch of service: ❑ Army ❑ Air Force ❑ Marines ❑ Navy ❑ Coast Guard

❑ Other: ___________________________________________________________________ Military status: ❑ Active duty ❑ Inactive duty ❑ RetiredMilitary discharge: ❑ Honorable ❑ Dishonorable ❑ Medical

Circumstances: ______________________________________________________________❑ No difficulties serving in military reported

Clinician’s comments:

XVI. Legal History.

Legal involvement: ❑ Pending charge(s) ❑ Prior arrest(s) ❑ Prior conviction(s

❑ Dismissed ❑ Juvenile offense(s) ❑ DSS involvement

❑ No legal history reported

Incarceration history: ❑ Served prison time ❑ Incarcerated over 2 years ❑ Incarcerated within last 24 months

Community supervision: ❑ Pretrial supervision ❑ Probation ❑ Parole

Clinician’s comments:

XVII. Personal Abuse History (Walker categories).

Physical abuse: ❑ Pushing ❑ Shoving ❑ Grabbing ❑ Punched with fists ❑ Pinching ❑

Clawing ❑ Scratching ❑ Kneeing ❑ Head banging ❑ Tied with rope ❑ Attempted drown

❑ Threatened with knife ❑ Threatened lethal weapon ❑ Slapping ❑ Hitting

❑ Spitting ❑ Pulling hair ❑ Biting ❑ Kicking ❑ Head shaking ❑ Choking

❑ Thrown objects ❑ Burned ❑ Threatened with gun Thrown against wall❑

Thrown on ground\floor❑ Sitting\standing up ❑ Hanging neck, arms, feet ❑ Wrestling❑ Thrown across room❑ Twisted arms\legs\fingers❑ Handcuffed❑ Hit with objects ❑ ❑

Forced eat non-edible\poison Threatened with automobile❑ No physical abuse reported❑If so, by whom ?

Duration\description:

Clinician’s comments:

Sexual abuse: Unwanted rough touching genital area❑ Forced anal❑ Forced ❑masturbation

Forced pornography❑ Sexual contact STDs known, suspected❑ Unwanted sexual gestures ❑ Hostile environment to women❑ Sexual touching of minors❑ Forced oral sex❑ Rough sex (genital bruises\mutilation)❑ Forced sex with other people❑ Sexual contact HIV positive❑ Taken advantage of (power) ❑ Sexual touching clothing\body❑ Forced vaginal intercourse: ❑ with orgasm❑ without orgasm❑ Insertion objects into genitals❑ Forced prostitution❑ Forced view others having sex❑ No sexual abuse reported❑

If so, by whom?

Duration\description:

Clinician’s comments:

Emotional abuse. Emotional\verbal abuse❑ Spiritual abuse❑ Abandonment❑ Neglect❑ Other: ____________________________________❑ No emotional abuse reported❑

Mandatory report: DSS❑ Police❑If so, by whom?

Complaint disposition: Accepted❑ Rejected❑Duration\description:

Clinician’s comments:

Witnessed abuse. Physical abuse❑ Sexual abuse❑ Emotional\verbal abuse❑ Spiritual abuse❑ No witnessing of abuse reported❑

Clinician comments:

Perpetrator of abuse. Physical abuse❑ Sexual abuse❑ Emotional\verbal abuse❑ Spiritual abuse❑ Abandonment\neglect❑ No abuse of others reported ❑

If so, against whom?

Duration\description:

Clinician comments:

XVIII. Developmental History (For Use With Children and Adolescents Only).

Prenatal.Duration pregnancy: ____ weeks Pregnancy history: Smoking❑ Alcohol❑ Illicit drugs❑ Sexual❑

Details: ______________________________________________________________________________________

Pregnancy complications: X-ray❑ Accident❑ Vaginal bleeding❑ Unusual occurrences:❑Pregnancy status: Age of mother: ____ Planned Unplanned

Reaction: ____________________________________________________________________________________

Physical condition of mother: Excellent❑ Good❑ Fair❑ Poor❑Explanation: __________________________________________________________________________________

Delivery status: Premature: ____weeks❑ Full-term❑ Birth weight: ____ pounds ____ ounces

Incubation required❑Delivery mode: Vaginal❑ Cesarean❑ Breech ❑ Multiple births Anesthesia used: Yes No❑ ❑ ❑

Type: Epidural❑ General❑ Other: _________________________________❑Delivery complications: Forceps: High Low❑ ❑ ❑ Vacuum tube❑ Oxygen required❑

RH disturbance❑ Maternal hemorrhage❑ Congenital❑Description: ________________________________________________________

Days in hospital : Mother: ____ Infant: ____ Reason: ______________________________________________

Apgar score: Score: ___ Physician comments: _________________________________________________

Method of feeding: Breast Age weaned: ____❑ Bottle❑Infant feeding problems: Vomiting❑ Poor sucking❑ Colic❑ Allergy❑Immunizations up-to-date: Yes❑ No❑ Problem(s): _____________________________________

No history of prenatal problems reported❑

Clinician comments:

Postnatal. Motor skills: Held head up❑ Sat without support❑ Began creeping❑ Began walking ❑

Other: _____________________________ Description: _______________________❑Language development: 1❑ st word 1❑ st understandable words Other: __________________________❑Description: __________________________________________________________________________________

Speech defects: _______________________________________________________________________________

Visual disturbances: ____________________________________________________________________________

Auditory disturbances: __________________________________________________________________________

Toilet training: Urine: Age began: ____ Age completed: ____ Bowel: Age began: ____ Age completed: ____

❑ Enuresis: Diurnal❑ Nocturnal❑ ❑ Encopresis: Diurnal❑ Nocturnal❑Regression, Loss of Skills, or Habits: ______________________________________________________________

Cerebral dominance: Right-handed❑ Left-handed ❑ Ambidextrous❑ Confusion❑Social attachment(s): Affectionate❑ Unaffectionate❑ Distant ❑ Detached❑Description: __________________________________________________________________________________

Behavioral adjustment: Controllable❑ Uncontrollable❑ Lethargic❑ Hyperactive ❑ Immature❑ Cooperative❑ Uncooperative❑ Normal activity❑ Other: _________________________________________________________________❑

No history of postnatal problems reported❑Clinician comments:

XIX.” Medical Necessity” Criteria.

Level of Functioning (Must meet all conditions). A. Condition diagnosed on Axis I (DSM-IV)❑ ❑ Reasonable expectation patient capable of changes as result of proposed treatment plan

❑ Global Assessment of Functioning (GAF) 70 or less, supported by clinical data

Functional Deficits (Must fulfill one criterion or more).  ❑ Evidence symptoms or behavior produce identifiable impairment, i.e. performance on job or in school doesn’t meet

marital/parenting or social/interpersonal responsibilities or self-maintenance capacity

❑ Potential for more serious illness without remediation current condition

❑ Readily identifiable potential for decompensation or life-threatening behaviors ❑ Readily identifiable potential for loss of impulse control

 In addition to above criteria, the following MUST be met:❑ Information, including mental status examination, current and prior mental health and substance abuse history,

psychological or laboratory results fit documented DSM-IV Dx

❑ Impairment(s) in central life role functions must correlate with DSM-IV diagnosis

❑ If patient meets criteria for psychoactive substance abuse disorder, treatment is provided in a specialized chemical

dependency program or organized aftercare program and involves consistent attendance at appropriate community

support groups

❑ Patient receiving medication or evaluated by a psychiatrist for DSM-IV classified disorder generally considered to

have biological causes or amenable to psychotropic medications

❑ If patient minor, evidence parental involvement in treatment plan appropriate to age and developmental level of

patient

❑ Evidence of appropriate medical evaluation or treatment for concomitant medical condition ❑ Evidence patient receiving psychopharmacotherapy are reevaluated at least every three months and for those

receiving anti-seizure medications, AIMS examinations performed at 6-month interval

❑ Evidence collateral contacts/support groups, i.e. families, social service agencies, AA, NA, CA, and CODA, etc.,

utilized where appropriate

❑ Comprehensive treatment plan corresponds with DSM-IV diagnosis(es), level of severity and symptom(s) or

behavior(s) producing identifiable impairment

 If request for treatment exceeds once per week, proposed treatment criteria also meets the following: ❑ Clinical data supports diagnosis of Axis I or II other than adjustment disorders or 309.XX; except, 309.21 Separation

Anxiety Disorder

XX. Recommended Follow-Up Clinical Assessment(s).

Comprehensive evaluation:❑ Forensic❑ Educational❑ Mental Health❑ ❑Custody

High Risk Model of Threat Perception [HRMTP] (Includes self-deception, absorption, negative affect)❑ ❑ Health Status Questionnaire 2.0 ❑ Outcome Questionnaire-45 Crisis Triage Scale❑ ❑ Timberlawn Child Functioning Scale : Parent form❑ Clinical version❑ ❑ Personality Assessment Inventory : ❑ Adolescent ❑ Adult ❑ Minnesota Multiphasic Personality Inventory—2 ❑ Projective Screening (Includes Bender Gestalt Test , Achromatic House, Tree and Person Drawings) ❑ Computerized performance test: ❑ IVA ❑ TOVA PADDS❑ ❑ QEEG: Quick❑ -Q TLC-Q❑ ❑ 19-channel ❑ 32-channel Psychophysiological stress profile❑ ABEL Sexual Arousal❑ Other: _____________________________________________________________________________________❑

Source(s) Providing Data: ❑ Self-report ❑ Parent/guardian ❑ Other:________________ 

Clinician signature: ____________________________________ Date of interview: / /2010

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Last updated: 06/27/2010