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Assessment: Initial Phase

Dale Pietrzak, Ed.D., LPC-MH, CCMHC. Assessment: Initial Phase. University of South Dakota. The Intake Interview. Initial Phase Intake Mental Status Exam Testing (Objective or Projective) Intermediate Phase Client-Therapist Interaction Testing. Termination Phase Meet Goals?

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Assessment: Initial Phase

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  1. Dale Pietrzak, Ed.D., LPC-MH, CCMHC Assessment: Initial Phase University of South Dakota The Intake Interview

  2. Initial Phase Intake Mental Status Exam Testing (Objective or Projective) Intermediate Phase Client-Therapist Interaction Testing Termination Phase Meet Goals? Dismissal Dx? Referral Appropriate? Assessment Process

  3. Interactional Nature of Assessment Components Intake Interview Test Results Treatment Plan and Goals Client Behavior

  4. Intake Interview Ranked as the most needed and valued skill by practicing mental health professionals 1 1Morrison, J. (1995). The first interview: Revised for the DSM-IV. New York: Guilford

  5. Determine areas of concern: type and severity of concerns Determine appropriate testing process Set stage for Relationship Determine general to specific treatment goals (initial and termination) Serves as framework for interpretation of testing Purpose of Intake Interview

  6. General Information General Concerns Relationships Developmental & Medical History Chemical Use Legal History Mental Health History Detailed Concerns Interview Checklist Intake Components

  7. Psychiatric Evaluation • Chief Complaint • History of Present Concern • Past History of MI & Family History of MI (screen for neurological impairment) • Med History • Medications & Drugs • Psychosocial History (pg 132-141) Zimmerman (1994).

  8. Psychiatric Evaluation Con’t • Mental Status Exam (pg 120-125) • Physical Exam • Differential Diagnosis • Treatment Plan I don’t know if I can do this!

  9. Initial Contact • Phone Contact • Waiting Room or Office • Identifying Information • Client Attitude • Treatment • Agency • Therapist And you would like the counselor to help with what else?

  10. Current Concerns: General What is the difficulty? What made client seek treatment now?

  11. Relationships: Past & Present • How does client handle closeness? • How does client handle conflict? • How does client determine friendships? • How does the client end friendships? • How does the client handle authority? • How does the client handle subordinates?

  12. Medical History • Physical conditions impacting situation • Medications impacting situation • Chemicals impacting situation • Learning difficulties/Developmental delays • Neurological concerns • Family history of conditions

  13. Legal/Financial History • Childhood to date • Types, severity and chronicity • Role in motivation in treatment • Financial difficulties • Role in concerns

  14. Mental Health History • Conditions • Treatments • Attitudes about Tx & Dx • Releases • Family History

  15. Current Concerns: Specifics • Specific Symptoms • Checklist • Interview form • Interview • Duration • Impact on areas of home, friendship, work (school), personal self-care • Things missed so far

  16. Integration • Summary of Information • Strengths • Weaknesses • Personal Style • Concerns/Diagnosis • Treatment Plan • Short & Long Term Goals

  17. The End

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