Chapter 4: Clinical

Assessment Form
Case Documentation in Counseling and Psychotherapy
Diane R. Gehart

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How to Complete a Clinical
Assessment
• Identify Client Information
• Presenting Problems
• Mental Status Exam
• DSM-5 Diagnosis
• Risk Management
• Case Management

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Identify Client Information
(Slide 1 of 2)
• Identifying Salient Client Demographics
• Age
• Gender
• Ethnicity
• Sexual orrientation
• Relational status
• Occupation
• Language
• Immigration status
• Significant physical disorder or considers

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Identify Client Information
(Slide 2 of 2)

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Presenting Problems (Slide 1 of 2)
• Presenting Problems
• Provides a quick overview of the client’s and/or family’s current
difficulties as they define them
• Primary reason client(s) seek treatment
• Secondary issues client(s) casually mention

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Presenting Problems (Slide 2 of 2)

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Mental Status Exam
• Comprehensive Overview Of Clients’ Mental Health
Functioning
• Typical Areas Of Functioning Assessed
• Interpersonal
• Mood
• Affect
• Sleeping patterns
• Eating patterns
• Trauma symptoms
• Psychotic symptoms
• Motor activity
• Thought
• Socio-legal issues

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Mental Status Assessment for
Identified Patient

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DSM-5 Diagnosis
• Contextual Factors
• Include age, ethnicity, family dynamics, language, religion,
economic issues, sexual orientation, trauma history, addictions,
cognitive ability
• Making a Diagnosis
• Use the DSM, Diagnosis and Statistical Manual
• Write code and include specifiers
• Medical Considerations
• Refer out when needed
• Medical Necessity
• presently significant impairment in functioning

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Diagnosis for Identified Patient

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Risk Management (Slide 1 of 2)
• Assessing Suicidality and Homicidality
• Assessing Substance Abuse
• Sexual Abuse, Physical Abuse, and Other Risk Factors
• Child Abuse
• Abuse and Assault in Adulthood
• Elder and Dependent Adult Abuse
• Other Risk Factors
• Anorexia, Bulimia, and Other Eating Disorders
• Cutting and Self Harm
• Criminal or Legal History
• Other Traumas

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Risk Management (Slide 2 of 2)
• Indicators of Safety
• Assess for the potential for safety
• Safety Plans
• Developed for any situation in which potential risk is identified
• Scaling for Safety
• Commitment to Treatment
• Client agrees to commit to the treatment process

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Risk and Safety Assessment for
Identified Patient

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Case Management (Slide 1 of 2)
• Resources And Services Needed
• Making Collateral Contacts
• Referrals to Resources to Support Need to Achieve Clinical Goals
• Creating a Support Network
• Prognosis
• Expected outcome, which is typically framed in terms of “return
to normal functioning”

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Case Management (Slide 2 of 2)

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Evaluation of Assessment
• Reflect On How The Assessment Fits The Client’s Unique
Needs
• Diversity factors
• Effects of treatment on the client
• Areas of client-counselor agreement/disagreement

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MENTAL STATUS TERMS

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Interpersonal Issues
• Conflict
• Enmeshment
• Isolation/Avoidance
• Emotional Disengagement

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Common Mood Descriptors
• Mood Versus Affect
• Depressed
• Anxious
• Dysphoric
• Angry
• Irritability
• Manic

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Common Affect Descriptors
• Constricted or Restricted
• Blunt or Blunted
• Flat
• Labile
• Incongruent

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Common Sleep Descriptors
• Hypersomnia
• Insomnia
• Disrupted Sleep
• Nightmares
• Night Terrors

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Common Eating Descriptors
• Anorectic Restriction
• Bingeing
• Purging
• Body Image Distortion

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Common Anxiety Descriptors
• Anxiety
• Chronic Worry
• Panic Attacks
• Phobias
• Obsessions
• Compulsions

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Common Trauma Symptoms
• Hypervigilance
• Flashbacks/Intrusive Memories
• Dissociation
• Emotional Numbing
• Avoidance Efforts

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Common Psychotic Descriptors
• Hallucinations
• Delusions
• Paranoia
• Loose Associations

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Common Motor Activity
Descriptors
• Low Energy
• Hyperactive
• Agitated
• Inattentive
• Impulsive
• Pressured Speech
• Slow Speech

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Common Thought Descriptors
• Poor Concentration or Attention
• Denial
• Self-Blame
• Other-Blame
• Ruminative
• Tangential
• Concrete
• Poor Insight
• Impaired Decision Making
• Disoriented

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QUESTIONS FOR PERSONAL
REFLECTION AND CLASS DISCUSSION
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Reflection Questions
• Which part of the mental status exam seems easiest to you?
Most difficult?
• How would you go about creating a safety plan with a client?
• What elements of case management will likely be most
challenging for you? Why?

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