Initial Assessment and Diagnosis Tips:
Here is the Training Video for completing this portion:
How to Document an Intake - https://drive.google.com/file/d/1iBZeLRdvh8n6POPpHNtkfGvKvz1h3oC9/view?usp=sharing
The Client’s Intake Paperwork MUST be signed before this appointment. If it is not, then the first 20 minutes of the appt need to be spent having the client completing these forms or cancelling and rescheduling for a time after these have been completed. This is because this is their consent to treatment and we by law can not treat someone without this.
A Sample Intake Is Included Below. We will be using the same client, “Practice Onme,” for demonstrations across the Portal.
Timelines: Initial Assessment and Diagnosis are completed within the first two scheduled appointments with the client. This document must be signed by you within 48 hours of the second Intake Session.
Please remember to still document progress notes referring back to the Initial Assessment and Diagnostic tab. Please see notes in the Phone Consult Test Client to see an example of this.
Reminder about Diagnosis: Please remember that an Adjustment Disorder Diagnosis is only valid for six months from the date that you give it, and a new treatment plan must be created as soon as you change the diagnosis so it is better to get clear on an accurate diagnosis off the bat.
Prior to First Appt. Please review all of their assessments, scores and challenge areas before the first appointment so you can have an idea of more questions to explore.
Goal of the Intake: The Initial Assessment should be a wide net of gathering lots of information. There will be plenty of time to dive deeper in sessions, but getting these questions answered first is so incredibly important.
Naming that the Intake Sessions are more structured to gather information and we will shift into more relational work as we continue.
Feel free to create a template from the Initial Assessments Questions to make sure you are touching base on all areas in the appointment.
Presenting Issue - Why here, why now? How is it impacting their mood, sleep, appetite, self-esteem, relationships, substance use, and unhealthy/unsafe coping?
Pertinent History - What is the history of the current issue? Chronic issue or acute? Other people involved?
Observations - What do you notice (this is also in the Mental Status of Progress Notes)
Appearance, Orientation, Behavior, Speech, Affect, Mood, Thought Process, Thought Content, Perception, Judgement, Insight
Family/Psychosocial - Current family structure (both family of origin and current) and quality of relationships, pertinent family history of mental health, substance use, abuse/neglect, etc., Friendships that are supportive/challenging would also be included here. Genogram (can be drawn by hand in session, and then scanned into the Clinical Documents folder, just reference this in this section),
Risk - Check boxes for current risks, the text box is to list any history of these risks including dates of suicide attempts, hospitalizations, etc.
Contract/Safety Plan -Complete if warranted. There is a form Safety Plan tab in Theranest. If this needs to be completed then note this in the text box.
Strengths - This will help clarify how the client views themselves alongside strengths you can use to support goals for treatment planning.
Involvement - You, client, alongside anyone else - spouse, parent, probation officer, family or couples therapist, etc.
Tentative Goals and Plans - What do they hope to achieve in your work together?
Treatment Length - Estimation here is fine
Is Client Appropriate For Agency Services? Is the client aware that we only offer weekly outpatient care? Are they stable enough to be only in 1:1 weekly outpatient care?
Cultural Variable? All clients have these - this can include raised in a religious home (which they may or may not still ascribe to), geographic differences in culture (raised in the rural south but now living in Boulder), adopted, served in the military. If client doesn’t name any cultural variable please type “Client denies impactful cultural variables. Clinician will continue to assess.”
Special Needs Of Client - Need For Interpreter, Interpreter For The Deaf, Religious Consultant, Etc. If yes, what?
Educational Or Vocational Problems Or Needs - Are they currently in school? Employed? Barriers to meeting these goals of furthering education or work goals?
