IDENTIFYING INFORMATION AND REFERRAL STATEMENT
Include description of client’s (individual, couple, family,c.) age, occupation, marital status and any other significant identifying information such as previous treatment at the Psychology Clinic (e.g., Mrs. M. is a 40 year old, single parent of three children, who works as a bookkeeper. Had previously been seen at the Therapeutic Clinic for one session. (See Intake on file 1/07/80).
Mr. John Andrew is a 42-year-old male, single divorced no children who has been on and off different jobs, most recent working as an independent contractor to a small carpenter company. Has contact with family but is distant. Andrew has 2 older brothers both parents are alive. Had previously been seen at the therapeutic clinic for one session before.
2. Indicate the referral source, such as self-referral, referral by a physician, or social agency, and if there was a specific reason for the referral (e.g., Mrs. M. was referred to the Therapeutic Clinic by the Family Resource Center because of alleged neglect of her children).
Mr. John was referred to the Therapeutic clinic by the by criminal justice system because of rampant drug use and possession. Mr. john is currently under parole and must attend court mandated treatment.
PRESENTING COMPLAINT:
State briefly what is the most distressing at this time and use the client’s own words whenever possible using quotes. Indicate what kind of treatment they desire or expect, and what results they hope for (e.g., Mrs. M. would want her boyfriend involved in treatment, though he reportedly refuses to come in; Mrs. M. hopes to “get along better with him” and “take better care of my children.”).
Mr. Andrew wants to overcome his addiction and self-destructive behavior; he has tried in the past by himself to do it with out any of his friends and family help. He does not want his family to know under any circumstance due to intense family relationship. Client stated” He hopes to get better and get his life back around so he can just focus on his financial situation”.
HISTORY OF PRESENTING COMPLAINT:
Describe in chronological order (and with dates) the onset and development of the presenting complaint and how it is manifested.
(a) Onset – when the problem began to affect or interfere with the client’s daily living or became manifest to those around him.
Mr. A started to notice his hear racing 2 years (4/2/18) the first instance occurred early in the morning, client stated “he felt that he just climbed 15 flights of stairs and would go away after 10 to 15 minutes”. No associated symptoms were notice at the time. Since then he would have these episodes 3 to five times per day when he wakes up in the morning or when he is at work. Has lost his close friends from the divorce but has made now friends at the local bar which he frequents daily.
(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.) and severity of stressors.
Mr. A has been through a difficult divorce 4 years ago (6/28/2016) and his work as a professional contractor has suffered leading to less work or unemployment on multiple occasions. Which has led him to be in the under constant financial strain which has increased his drinking and smoking substantially.
(c) Previous conditions, psychiatric hospitalizations and/or treatment which were similar to or the same as the presenting complaint (this information is often asked on insurance claim forms).
Client has had no Diagnosed medical illnesses. Has never had surgery but has broken his left arm on the job (8/02/13) and was in a case for 6 months with 3 months of physical therapy after.
MEDICAL: Currently under no medication but has been noted that he drinks excessively and smokes more than 2 packs per day.
PERSONAL HISTORY: (Only if applicable) If personal history is not utilized, significant events or changes may be documented in Therapist Notes, Transfer Summary, or Closing Summary,
This should briefly include any relevant occurrence (developed chronologically) and can use the following headings as a guide:
(a) Birth and Infancy: Were there any difficulties or special circumstances (medical, adoption, frequent moves, etc.)
Client was born as a preterm at 35 weeks. Client was hospitalized when he was born, has had no further health complications.
(b) Childhood: Overall adjustment and relationships to peers as well as academic performance (e.g., did above-average work in school and reported positive peer relationships).
Patient has had a regular upbringing from what he can remember. His parents provided for him and has never felt wanting. He was very affection with his parents and brothers. He did average in school and was mostly a C/B student.
(c) Adolescence: Further development including any behavioral changes, family circumstances, peer adjustment, education, and relationships with the opposite sex.
Client had a hard adolescence with his mother’s death due to a traffic accident. It had changed the dynamic in his family and his once affectionate father was cold and distance usually drinking in the middle of the day. Client had no issue with relationship with the opposite sex. Client did say that his grades were no longer a concern at the time and his education suffered because of it. This was the time he discovered smoking and became addicted to it at a young age.
(d) History up to time of presenting complaint including vocational information, dating/sexual experiences, and marital relationship(s) if applicable. Note present living arrangement and significant socio-economic circumstances or influences.
Client lives alone in a small apartment. He went to technical school to learn about management before entering the construction field. After the divorce 4 years ago, he hasn’t really been interested in any sort of real companionship. He has 2 older brothers but rarely sees them. client have some friends that he meets at the bar during the week, though he rarely does anything other than that with them. He doesn’t know why he drink so much, and he feels that he has nothing better to do and have fallen into this habit over the last 4 years.
CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:
Include (1) pertinent dynamic factors in the development of the presenting complaint, taking into account psychological aspects of the client’s life (e.g., family; employment, etc.), (2) appraisal of insight and motivation for treatment, and (3) level of functioning or impairment, including the client’s own strengths and resources.
Areas of functioning and/or impairment should focus on: (1) symptomatology, (2) productivity (employment; activities of daily living), (3) capacity for pleasurable experiences (hobbies; entertainment), (4) interpersonal relationships, (5) capacity to handle ordinary conflicts and stresses. Assess and record whether impairment or reactions in these areas are mild, moderate or severe.
Note any significant information which might mean the client is “at risk” (suicidal ideation, homicidal ideation, etc.).
[Where applicable briefly note and/or assess defenses, affect, behavior, personality style, traits, and patterns. In evaluating the client, take into consideration the mental status examination.]
MENTAL STATUS:
TENTATIVE DIAGNOSIS:
(1) According to DSM V, or (2) Dynamic formulation with clinical features, or (3) Reason for contact with the agency.
CASE FORMULATION & TREATMENT PLANNING RECOMMENDATIONS:
Case formulation is the bridge between clinical assessment and treatment planning. (See page 415 textbook). You attempt to synthesize all that has been learned about the patient’s past, so as to point the way to a better future
Several reasons for preparing a formulation: (1) To focus your thinking about the patent, (2) To summarize the logic behind your diagnoses, (3) To identify future needs for information and treatment, and (4) To present a brief summary of the patient.
State type of treatment utilized (e.g., crisis, insight-oriented, supportive, behavioral, psychotherapy, etc.), the treatment modality (e.g., estimated length of treatment, changes in modality, etc.). Include designation of the primary therapist(s) (e.g., Will be seen by the undersigned and Ms. M, in group therapy).
(a) Treatment focus and/or goals with specific reference to the client’s “reason for seeking treatment.”
(e.g., Initial treatment recommendation is individual psychotherapy on a once weekly basis. Therapy will focus on Mrs. M.’s presenting concerns around her relationship with boyfriend and child management issues. Couple treatment is possible in the future, but boyfriend presently refuses to attend sessions. Will work on symptom relief (early morning wakening) and increasing her ability for pleasurable experiences
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