How To Structure A Mental Health Intake Assessment

The Clinical Loop: Part-1/3: How to Structure A Mental Health Intake Assessment.

How To Structure A Mental Health Intake Assessment

In this video, I discuss how to structure a mental health intake assessment.

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–Gratitude Journal–

–Guided Meditations–

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TRANSCRIPTION

Hi, are you trying to figure out how to structure a mental health intake assessment while you’re in the right place? So stick around and I’m going to walk you through step by step how I structure and take assessments as a mental health professional. After a decade of experience and why it’s important to consider this as the first part of the clinical loop. OK, so let’s get to it!

Hi, my name is Patrick Martin and after meeting me for the first time I’m a mental health professional by trade. I am passionate about raising mental health awareness and teaching actionable coping skills and ways to be more productive. In this episode of the video podcast I’m going to teach you how to structure a mental health intake assessment. 

As I walk through this, I want you to keep in mind that this is the first part of the clinical loop and the clinical loop consists of three phases. The intake assessment, the treatment plan. 

And progress notes, and we’ll talk more about that in a bit, but I wanted to take an opportunity to create this episode for you. And if you’re listening on the podcast, you’ll still get value out of this. If you’re watching on the video, you can follow along. 

I don’t know about you, but I I like to toggle between both depending on what I’m doing. If I’m taking a walk, I like to have a podcast going. If I’m sitting and relaxing, I’d like to watch YouTube tutorials, so best of both worlds. 

In this episode of the video podcast, I’m going to walk you through how I structure mental health intake assessments and also why it’s the first step in the clinical loop. The clinical loop consists of three parts, the intake assessment, the treatment plan and progress notes, and as I walk through this, I’ll try to explain my thought process and how I ask questions why ask the questions but I’ll keep it as quick and simple as possible and you can always ask me to elaborate and I’ll be more than happy to do so in any future videos. OK, let’s go. 

Consent

Alright, so the first thing to consider when you’re conducting an take assessment is of course informed consent right? I usually start off the conversation by asking clients; Have you ever been through this process before trying to keep in mind what it’s like to be on the other side of the desk and get into? 

The mindset of the person that you are speaking to, because if it’s somebody who has a lot of treatment history in the mental health system. They’ve they’re probably very familiar with the intake process, the type of questions the rigamarole, but if they’ve never been through the intake process, it could be pretty scary.

They don’t know what to expect, so it’s always good to start off by just letting them know that a of course everything is confidential and private won’t be shared with anyone else without their informed consent. 

Explicit consent. Of course it falls under mandated mandated reporting laws right? And so it’s important to just keep in mind that it’s well worth your time to educate the person on the other side of the desk or the other side of the phone or the other side of the camera, depending on what your modality is, Tele health, face to face, and help demystify it for them, so I usually say something along the lines of:

Orient Them To The Process

“you know the intake assessment is just a process in which we’re gathering history in order to get a bird’s eye view so that we can figure out how to best help you, and also put together a plan to see how we can be of service and meeting your goals”; or something along those lines, and just let them know that there’s nothing behind the curtain.

This is mostly history gathering process, but also as a clinician, we’re looking for points of intervention for future implications in terms of how we can intervene, what their target behaviors are. 

Are there any compensatory behaviors, as well as any other clinical relevant information, such as grief, loss, strengths, weaknesses, environment, bio-psycho-social stuff. 

OK, so the first thing I want to bring your attention to is of course modality. So if this is something being done via Tele Health, which you know, given that this is the Covid-19 pandemic and pretty much all treatment is being done over the phone or over Tele health right now, it’s really important to consider the modality so that you can you can put into your assessment or at least assess for what the circumstance is. So, for example, if it’s being conducted by telephone, you definitely want to document that that this is being done by telephone and you’ve reviewed emergency protocols with your client in advance. 

Location

And in the same vein, you want to be sure that you understand where they are. So you want to document their location. Very important in case of an emergency. So you want to know are they home or they have their car. If they’re in their car, where are they? And so forth. 

So. 

Referral Source

And other than that, the first question I’d like to start off with is the referral source. You know, how did you hear about us? Who? How did you you know who refer to you as a family? Was it a friend? Was it your primary care provider? Was it another mental health professional? ’cause that gives you a lot of information and also what the motivation is, is this? 

Um, a self identified problem that brings into treatment or is this? 

An issue that’s been brought to their attention by somebody else or even oftentimes mandated treatment through, like the court, children, Family Services and that’s equally important to know because that’s going to help prime your mind for how you’re going to what you’re going to be looking for during the assessment. In terms of how to best help this person and what their level of motivation and even insight is. 

Into what the whole mental health platform has to offer them in terms of their needs. ’cause a lot of people they look at mental health as just being sometimes about thoughts and feelings, but they don’t necessarily think about it as a resource you know to meet their other basic needs.

Help them problem solve barriers for those needs and so it’s a great opportunity, especially if it’s somebody’s first time getting to mental health. 

To educate them about exactly what mental health is and to address any underlying assumptions they might have about it.

Presentation

Alright, so presentation. This is basically something I I’m mindful of. You know you’re paying attention to their affect. Their stated mood. Is it congruent incongruent? Their age, ethnicity? Do they have children? Do they not have children? And oftentimes this is something I’ll come back to after I’ve asked the rest of the questions. 

And I’ll fill in once I have a better, better idea of what the whole picture looks like. It just helps me write the presentation. 

Later, after I’ve asked most of the other questions, it’s almost like a brief summary before I do the clinical summary. I don’t know if that makes sense, but it will OK, and then the primary complaint. This, in my opinion, should be the client’s own words, so this should come directly from the client or the horses mouth. If you were and. 

Primary Complaint

You can paraphrase. I paraphrase sometimes, but the idea here is that the primary complaint is going to speak directly to the goals when you’re formulating the treatment plan. OK, because oftentimes we have a certain idea. We make assumptions about what a client is going through based on their history, but nothing is more valuable. 

Then getting their own words.

Oftentimes. They all want to say something like. I just don’t want to be anxious anymore or I just want to be happy or I don’t want to be depressed. And it’s our job to really tease out what that means specifically in actionable terms, right? What does it mean to not be depressed? Well, if you’re anxious, how often are you anxious, you know? 

Frequency and intensity. How is this, more importantly, interfering with your life, your quality of life? Is it causing problems in your relationships? Is it causing problems at work? Is it causing problems in school, you know? 

The more specific we can get with the impairments, the easier it’s going to be to formulate a treatment plan, which is the second part of the clinical loop.

Being cognizant of how these things tie together, because the assessment should inform the treatment plan and the progress notes from therapy that the actual treatment should reflect progress toward the goals. The stated goal is the treatment plan, right? So that’s why it’s called the clinical loop. 

Religious Practice

Religious practice. I always like to start with this question after the initial complaint, because it’s important for us to be sensitive not just to someone’s spiritual beliefs, but also because how relevant is that? And that’s an easy one to miss. If if we just drive past it. 

And so they might say, oh, Catholic Christian, Jewish, Taoist or whatever, you know, or agnostic, and we can leave that alone. But I like to dig a little bit deeper and find out how does their value system inform their quality of life, maybe they used to be very involved in church and they’re not anymore. That’s important to know that’s something we want to pay attention to, OK? 

Symptoms

Now, in terms of symptoms, it helps me to list things out kind of break it apart. So what I’m asking about symptoms, I’ll drill down a little bit. More specifically, I’m looking for depression and anxiety and of course any psychotic symptoms. Try and parse all those out so they can be more specific. 

So somebody’s complaining of feeling depressed. 

It’s important to know, of course, how often they’re feeling depressed. How long-lasting is that depression? 

How intense is that depression, and specifically what symptoms surround the depression.

Somebody is not going to say I’m anhedonic or I suffer from hypersomnia, hypersomnolence or insomnia. Even sometimes they’ll just say like, well, I can’t sleep and when I try to sleep my mind is racing and then I worry about my future and….

You know they will use different language, so it’s our job to kind of tease out that language and then kind of wrap it back up into clinical terms, right? That makes sense to us and so this will help us distinguish and determine out clinical impression. 

Is this A major depressive disorder or is this indicative of a bipolar disorder. They start to drill down on what’s specifically going on and what that looks like for somebody; you will get a better idea from a recall of lived experience. 

The relevance when we’re looking at diagnosis are differential diagnosis, and so there’s no right or wrong here, absolutely. 

It is important though to consider. 

The details, yeah, because the duration of depression, the intensity of depression, and how that coincides with other other things like mania, hypomania. You know their complaints of panic disorder. Those are all relevant and oftentimes indicative one to another, OK. And when it comes to onset, you know oftentimes the client will complain about it; “oh, I’ve been struggling with this for years or as long as I can remember”.

But do try and challenge your client a little bit more on when did they first notice it, and what did life look like, and at the onset of anxiety may look different than the onset of depression, which may be different than the onset of psychosis; if they struggle with all three, you know. Their first experience of paranoia may differ from their first experience of a panic attack or their first experience of a major depressive episode. 

And so it’s kind of important to tease those things out and make sure you’re accounting for the timeline on each of those. And so I’ll apply, you know, under depression I might put a different onset or under onset all kind of list out onset of depression onto the anxiety instead of 1st psychotic episode. And if they do differ, kind of tease those out from each other because it’s relevant. 

Sleep

OK, so sleep. You know when we’re assessing for mental health, it’s really, really important to get an idea of what somebody’s sleep looks like because. 

That’s really a big clue in terms of where their struggles are, and oftentimes is one of the biggest things that we used to help tease out symptoms of, say, a bipolar disorder, and then the kind of sleep patterns there, because yeah, insomnia might be a symptom of depression, and so is hypersomnolence.

It’s a symptom for anxiety too, right? And so it could also be indicative of, you know if there’s a pattern to the sleep cycle hypomania, or mania, not sleeping for four five nights at a time, feeling lots of energy. Those are things we want to pay a lot of attention to because we never know what’s going to be relevant, so we are sure to be careful not to drive past the subject of sleep hygiene too fast. 

I try to be very mindful of not being cut and dry with the questions, and so, oftentimes I will bounce around and that’s why I have this kind of written out on a Word document because I do jump around a lot because it’s more natural. That way you’re following the client, you’re letting them share, right? That free Association. 

So you can pick what’s relevant and circle back to those things ’cause everything is relevant. But oftentimes if we force a client into closed ended questions, we’re not really going to get a whole lot. You know, which can just lead to “yes” and “no”s, and very short statements. But if we allow clients to talk and share what’s most relevant to them we can kind of redirect the conversation if it gets off off topic too much, for the sake of time, but then we can also pick out things that we may not have otherwise considered, so it’s really important not to pigeonhole the client too much into answering specific questions in a specific order. 

But this is the general structure, just keep in mind I do like to jump around a lot depending on what what’s being expressed.

Dependents

OK, dependence. This is a really, really big one, because when it comes to assessments, not just because of the family structure, but because of risk issues. 

We want to be mindful of whether somebody has children, how many children do they have? Always trying to assess for special needs. If there’s anything going on, so you can start to assess for any kind of support referrals they might need if they’re overwhelmed. If there’s a caretaker burden. Also, if there’s any custody issues. 

So definitely you want to assess for that you know somebody says they have Children.

I always like to ask if you know what the arrangement is. Oftentimes children can have different parents and there might be different situation there that might be history of abuse, domestic violence. There might be court orders, and so those are always things you want to kind of tease out. You don’t want to drive by that too quickly because you’ll end up having to assess for that later anyway, and you’ll end up maybe having to revisit that in more detail further on into treatment if you didn’t get enough information on the front end, OK. 

Loss

So loss, keep in mind that loss is not always death. Oftentimes loss can be loss of a job, loss of relationships, loss of identity, role transitions. So when we’re assessing for loss, I do try and start the question off with, you know, have you had any recent deaths or losses in the family? But then, if they, even if they say no, I’ll back out a little bit and say, well, what about other changes you know in your life, any major changes that you’ve been going through and so often times that’s when they’ll start to identify other forms of loss. “Oh yeah, you know I’ve been going, you know, I just broke up with my girlfriend of 18 years.” Well, that’s significant.

That’s a loss, but maybe they weren’t thinking of that as a loss because it wasn’t a death and so we need to be. Oftentimes careful to clarify what we’re asking, right? Because if we don’t, if we don’t elaborate, then clients will often just make assumptions like we all do, right, and they may not give you the details that really do matter when it comes to the assessment, OK? 

Strengths

The other thing that is equally important is strength. So we definitely want to be assessing for strength, and this is really, really important. 

With the assessment is because this is what’s going to really move the needle because we want to be able to figure out what somebody has in terms of leveraging and their repertory, their coping skills. You know it’s going to help them move toward their goals and cope with future stress. 

So strengths might be art, music, creativity. I might be a skill set. It could be unbelief. System could be a lot of things. Maybe somebody who loves the outdoors. But since they’ve been depressed, they’ve neglected that part. Or maybe ’cause there’s been a life change, like the pandemic. They stopped going to the gym and that was really A big part of their life, so as as a clinician it’s our job to kind of tease out. OK well, how can we leverage those strengths in a different way that maybe they haven’t considered like if they used to love the gym. 

We want to ask have they been working out at home or are they caught up in that black and white thinking all or nothing thinking and so it’s part of our job to tease that out so that we can help them formulate ideas to start leveraging those strengths again, OK? 

Self-Harm and Violence

So it goes without saying that we want to assess for self harm and violence, right self harm such as self injurious behavior. 

Right? 

That could be superficial. History of like cutting. We want to find out where they’ve been cutting, if that’s if that’s a concern. That’s also indicative of potential diagnosis of other other conditions like borderline personality disorder.

Or if there’s been a self interest behavior as a form of suicidal ideations or testing themselves or even an expression of seeking help from others, or if there’s been any actual suicide attempts such as trying to end their own life, and if so, we want to definitely find out if you know if they did try and hurt themselves or they did try and their life. 

What stopped them? Was it a failed attempt? Did somebody intervene? It’s also relevant to future implications because it will advise us of any kind of red flags in the future of simply trying to overdose on pills in the past. That’s important to know because that’s something to watch for in the future, right? 

Equally, violence you know is really important to assess for because. 

Even if somebody doesn’t have a history of violence, we want to kind of find out what their relationship to violence is looked like, and also other propensity toward violence is. And if they have a history of anger or impulsive behavior, we want to find out a what’s triggered that behavior an be what helps mitigate that behavior. OK, again, we always want to be assessing for risk. 

And sometimes that won’t always be relevant until we start getting into other history of triggering situations, and then they’ll bring up something. Oh yeah, you asked me about violence. Well, there was this one time and so that’s why it’s important that you want to circle back with any added information, even if you’ve already kind of passed that question. You want to be sure to come back and kind of Plug that back in.

Contributing Factors

I always like to to tease out any contributing factors to stress right or tp their their primary complaint and so. 

This might seem a little repetitive regarding some things like loss, but it’s also real time issues like financial stress/debt. You know you want to drill down those things and find out well if they’re stressed financially. Is it just unemployment or is there more going on? Do they owe people money or are they in debt? 

Are they unemployed? How long have they been unemployed? You know, if it’s a relationship issue, we want to find out why that breakup was so difficult. So when it comes to contributing stressors, we really want to kind of look at in real time and history. 

As far as what’s kind of what weighs on them on a regular basis, right? 

Hospitalizations

OK, moving on. So now you know we’ll talk a little bit about hospitalizations. This is a quick can. Be a quick question, you know. Have you ever been admitted to a psychiatric hospital? Have you ever been on a 5150 yes or no? You know, but sometimes it’s. 

“Well, I was taken to the hospital. I was assessed but I wasn’t kept on a hold, you know or they didn’t keep me overnight.”

Those are things to assess for because it’s not just hospitalizations we want to tease out. It’s also like ER visits for panic attacks or suicidal thoughts, even if they weren’t didn’t meet criteria for 5150, it’s still relevant and important to kind of assess for any warranted concerns that led them to seek emergency assistance. 

If they have been in the hospital, it’s usually a good idea to get the dates right, the dates, times of visits, which hospitals they went to an, then how much they how much insight they have as to why they were there as well as what what followed up with in terms of their stay there where they discharged with medication, how much medication, what kind of medication were they given and discharged with? 

Did they have blood work done? If they have their blood work labs, that’s really important. And then if they’re if they’re open to it, you can always get a release from the, you know from the client for the hospital and then request the hospital records and so that can be very telling as well as discharge summaries lab results. That kind of stuff like drug screens can all be very relevant, especially if you’re working in coordination with a psychiatrist who’s going to want to know those things anyway, because psychiatrists will often order their own blood work, and if they have labs on file somewhere specially recently, it’s a good idea to have those OK. 

Mental Health Outpatient History

So mental health history in terms of outpatient services, that’s definitely something we want to assess for. You know where they had treatment? Have they ever been in counseling? Even if it was lay counseling with pastor or priest. 

Even in childhood where they any kind of services or programs you know, all of that is relevant and as much as possible, we want to be able to create a timeline of treatment and also trying to assess for you know what was helpful. So you’ve been in therapy in the past, what worked, what didn’t work.

What was thier experience like? That can be very telling as far as what their expectation is moving forward and also something was helpful. How we can leverage that? 

OK, if something really turned them off as far as treatment, we want to be sensitive to that as well, OK? 

Medication History

Medication support services. That’s a really a big thing. We want to assess for, you know, in terms of what medications have they tried. 

Were there any allergic reactions? 

Side effects what their experience has been like and what they’re currently taking, especially important to to find out if there’s been any reluctance to medication or any trouble with taking medication as prescribed, because that’s one of the biggest factors and people relapsing with mental health conditions is stopping medication because they don’t like the way it makes them feel or they it makes them feel like they have brain fog or they they feel they don’t feel motivated or they feel more blah. They lose their creativity.

There’s a lot of complaints with medication, libido and other things that can cause a person to stop taking their medication, but oftentimes people will stop but not talk to their psychiatrist or provider about it because they’re embarrassed. 

And so they’ll just stop and not say anything. And then we find out that’s why they ended up back in the hospital with a manic episode just because they stopped her medication. They had a valid complaint about it, but they didn’t expressed that for whatever reason, and that’s worth exploring, because treatment compliance is a major factor in recovery and for a client or consumer to feel safe talking about any apprehensions of their treatment is equally important to assess for OK. 

Substance Abuse

So in terms of substance abuse, you know we do want to find out, you know, do they drink alcohol? Do they smoke cigarettes? If so, how much and then any other drug history and. 

Also educate, you know if they if you tease out and you find out they do have a substance abuse disorder or some kind of dependence. This is your Golden opportunity to just offer. Ask if they’re willing for you to share some information on resources and then if they are, it is your Golden opportunity to really offer up some resources for inpatient outpatient treatment and also educate them about risk factors with alcohol and other substances so you can just kind of equip them, even if they’re not ready to make any changes right?

At that time you can start the conversation right there during the assessment and build that report early on. If it becomes a larger issue later on, you know at least you have that foundation and you might be surprised how open they are to intervention. Sometimes people are like, “yeah, you know, I’ve actually been thinking about that a lot and I would like to do something about it.”

You know, then you can equip them and even offer linkage if they need to. OK one example would be like the SASH hotline or refer them to the SBAT service locator tool. If you live in the LA County area, the SASH hotline will do a quick assessment screen over the phone with them and link him right to inpatient or outpatient services. So very helpful. 

Trauma

So trauma. Keep in mind that when we’re assessing for trauma, it’s important to give them permission to not share everything. If they’re not ready. ’cause if you push too hard during the assessment for trauma, it can be a real turn off and they may not say anything, but then they may not come back because if you open something up that they’re not ready for, oftentimes they won’t say anything and they just won’t return for services. So it’s very important to. 

Give them permission to share as much as they like, but not anymore than they’re comfortable with. 

And then also understand that all trauma is not the same. So don’t just assess for physical or sexual trauma, but definitely also for witnessing violence growing up. What was it like growing up in their neighborhood? 

There’s a lot of different types of trauma. There is an emotional abuse, psychological abuse, neglect, trauma as an adult in relationships, domestic violence. So it’s just really important to keep an open mind when you’re asking about trauma and not just ask I’ve ever been abused. 

That won’t suffice, oftentimes, because they may not. 

It may not register with them. What you’re asking, OK? So take your time with this one.

Medical History

Medical, so it’s really important to a find out of course what kind of insurance they have and if you’re in California and for example they have medi-cal, it’s important to understand what kind of medi-cal, because you can oftentimes help link them to other services depending on what type of medical they have, what carve out. 

And if they have private insurance, you know it’s good to understand, kind of what they’re working with in terms of what their options are and also who their primary care provider is. You know if they don’t have a primary care provider, it’s our job to really make sure they’re linked, right? And they know where to go.

Did they get their their annual physical and blood work and all that good stuff because we can’t negate the General Medical and and talk about mental health issues only, because they’re married. We can’t separate them, and oftentimes General Medical issue have symptoms that mimic mental health issues and they also compound and aggravate mental health issues, and so talking about somebody’s General Medical care is really, really, really important part of their treatment. OK,

We always want to assess for their last physical. You know how long is it been, not just listening to their heart. 

When did they get blood work done? You know what did that blood work look like? Did the doctor review their labs with them? Was there anything flagged low vitamin D levels? Low vitamin B levels? High cholesterol? You know all of that stuff is relevant. 

We definitely want to assess for any medical history, so this would not just mean like. 

Diabetes, cancer, heart disease. This would be. 

Any history of surgeries? So did they have their Gallbladder removed? For example, we want to be very mindful of any any medical history that they’ve had in terms of treatment. OK ’cause again, we never know what’s going to be relevant and it’s really important that we take the time to kind of walk through this and not drive past it too fast.

OK, allergies. 

This is not just allergies to food and medication, but oftentimes seasonal allergies. We just want to be really sensitive and and thorough to make sure that we’re we’re capturing everything, because that is a risk factor. Allergies is a risk factor, and oftentimes clients will say well. When I took Abilify, you know I had this reaction as a medication that they. 

A doctor may try and prescribe them so we want to be aware of that, so that if we do refer them to a psychiatrist, we just remind them to let the psychiatrist know. Hey, I had a bad reaction to this medication, right? So that they don’t have a similar experience, which again could cause them to back out of treatment. 

OK, any sleep disorders? 

Sleep apnea right night terrors, sleep paralysis, sleepwalking. These are things we want to definitely be assessing for OK. 

Head trauma right? This could be a motor vehicle accident. This could be physical abuse in childhood, which one make sure you know, ask, have you ever had any lacerations? If you did have any head trauma, did you have a CAT scan? How long ago was the head trauma? These are all relevant issues. Any history of seizures and something I really like to kind of add on is diet so. 

Again, we can’t really separate physical health from mental health. If somebody is not eating properly and they’re not getting a proper diet, or hydrating that will have an impact on their mental health. So we definitely want to make sure that they are. 

Diet. You know that self Care piece is being attended to and that they’re educated about what’s going on, especially if they have co-morbid issue like diabetes who want to be sure that we’re linking them to valuable resources to help manage their diet. Maybe they don’t know how.

Asses if they are seeing a dietitian or if they have no idea what a diabetes educator is. You know we can help link them and help look those things up for them, even in real time. I do that. Oftentimes, I will help them find resources to well, well, it’s still top of mind while we’re talking about it that way. Again, it’s our job to help you quit people. 

To be their best selves, right? 

You also want to assess for if you know weight, height, BMI, that kind of thing, because you may be on the phone with someone for an hour, 2 hours, or doing an assessment that is not face to face and not even realize that they’re morbidly obese? Well, that’s good to know, right? We could have just completely missed that, because if somebody is not physically in front of us. 

It’s it’s an easy thing to miss if we don’t ask, right? And they may not feel like it’s relevant, or they may not even think to bring it up right? And then any medical history in the family you want to be sure that you’re paying attention to those things in terms of risk factors, so that could you know. Just ask, do you have any medical issues in the family that you’re aware of? Heart disease, diabetes? 

Cancer. 

And then usually if there is, people will know about it. 

And it’s again something that would be easy for them to forget to mention, unless you ask. 

And then, equally important, is history of mental illness in the family. So if there’s a history of bipolar in the family or a strong history of anxiety or depression, that’s a predisposing factor. We need to know about that so we can list that out as a risk factor, OK? 

Especially if they haven’t. If there’s a strong history, for example of bipolar disorder, and you’re talking to. 

An 18 or 19 year old who’s experiencing high anxiety and mood swings. You should in the back of your head be thinking you know this. This person could be looking at having their first manic break at you know 20 to 23. You know that’s something to look for because stress management is going to be really important. Part of the treatment plan. 

Education

Alright education so not just did you finish high school or are you in college but we’re looking for things like where you ever diagnosed with a learning disability in school? Were you ever on an IEP? What did that look like for you? 

I also like to take an opportunity here and talk about goals. So if somebody has educational goals for college for example, but they didn’t get to that or they haven’t gotten to it, we want to find out why, because a big part of the assessment is identifying needs and goals, but also barriers. 

You know how can we help this person think through and problem solve their barriers? There’s probably resources they didn’t even know about. For example, disabled student services if they were, if they need help with accommodations, or if they can’t afford school thinking about things like Department of Rehabilitation that will help pay for their training and their higher education. 

Those are definite things we want to be assessing for OK. 

Employment

And then employment. You know if we don’t find out what obviously somebody’s employment status is, or the unemployed. Are they working? How many hours? What kind of job do they like their job? You know? Also what are they done in the past? So what you know? What are all the jobs you’ve had? And I always like to ask which one did you enjoy the most? 

Because. 

When it comes to our mental health and our quality of life. 

If we’re doing what we enjoy the most. 

It has a ripple effect on everything else, right? And so I I always try to encourage clients and we want to focus on jobs that speak to your strength and not your weaknesses, right? And oftentimes they will just look at a lived experience of a job they’ve had that didn’t go so well, and they’ll make assumptions about their ability to perform. And that’s not necessarily the case. 

It just wasn’t the best environment or a job for their skill set, their personality, their mental health, OK? 

Legal

So legal issues, of course. We want to find out if anybody has. 

You know illegal status, probation, parole. Those things are important, especially if they’re being referred by their probation officer or the court or diversion program. Any of those things, or if they do have a legal history but they didn’t want they had not brought it up yet and they have a probation officer, parole officer. 

They may, you know, it’s important to find out. “Do you want to sign a release of information so that if this person wants information about your treatment, we have permission to share that and so all of those things are relevant?” And also if somebody has a history of arrests and one of those arrests looked like what were the reasons? What were the circumstances? 

And so all of that is relevant because oftentimes people end up incarcerated because of their mental health issues, but they were never flagged as having a mental health problem. You know, in the forensic system, and so that’s also something worth teasing out. OK, and if they get arrested again, it’s important for them to know how you know to inform staff so they get proper treatment while incarcerated.

Housing

Right, the legal system of their mental health history so that that can be addressed in their incarceration and not just for their stigmatized right? OK, so housing, right? We definitely want to figure out, you know what somebody’s housing situation looks like. So do they live alone with family? The household constellation? So how many people are in the home? What ages are they? 

And drill down a little bit more and figure out what are those dynamics look like. Do you sleep on the couch or do you sleep in your own room? Do you have your own space? Do you share a room? How do you feel about your space? How much privacy do you have? All of those things are extremely relevant. You know we’re talking about an assessment in somebody’s mental health and quality of life. Because this is their day in. 

They out experience and you know between the times that you see them. This is their life and so. 

The better picture you can paint of somebody’s daily existence, the easier it’s going to be to kind of get inside their head and think about, well, if I’m this person. What are my needs? What would help me? 

You know thrive would help me improve my quality of life and so those are oftentimes things we can consider. And if they’re homeless, for example, they may not know what resources are available to them. They may not know about things like Volunteers of America or collaborative shared housing and things of that nature, or how to get into a Section 8. 

Waitlist or HUD housing there’s or even a family shelter right? If somebody’s in the streets with their kid and they’re escaping domestic violence, they may not even know about DV shelters for women. So there’s a lot of things that we want to be able to consider. 

When we’re talking about housing, it’s a big one. 

And homelessness is a huge issue right now and not just because of the pandemic, but in general OK. Family dynamics and structure. So this is definitely where you want to drill down on what somebody’s experience was like growing up, who raised them, where they raised by a single parent, where they raised in foster care Group home. 

Family History

Assess for family of origin and family of choice.

Where were they born, who raised them, what was their home life and childhood experience like, how many siblings do they have?

Were they raised by grandparents who you know have recently died, and that’s that’s a major loss for them. ’cause that was a parental figure. We want to find out if they have any siblings. Do they stay in touch with their siblings? And then of course, who are they closest to and their family? That’s really important. You know those attachments and trying to figure out what that looks like. If there’s any unresolved issues with their parents. 

See if they have ever been married, how many times they have been married? How long have they been divorced? Have they ever been widowed? 

How many kids do they have? What does their relationship with their kids look like? All of those things are extremely relevant. OK, and this is also where I would plug in if there’s any DCFS issues. You know custody issues, legal issues they’ve ever lost children to DCFS, you know custody and that kind of thing, so this is a big topic. 

And then I once you tease out some of that, you want to find out what their support system looks like. So I usually ask, you know, where do you get most of your moral emotional support from? Is that from family? Is that from friends? Is that from a particular group or your church? And what does that involvement look like? 

That could be an online forum that could be a Facebook group. Could be a number of things, but it’s again the better picture we get of what this person’s social network that looks like. The easier it’s going to be for us to kind of figure out where things can be leveraged, but also where we can plug some stuff in and help clients think through how to build out a better support system.

Clinical Summary

And then that brings us to this summary. So this is the clinical formulation, so it’s kind of taking all of that stuff and then packaging it in a way that makes quick, quick clinical kind of snapshot of what’s going on. And so this is often times where I look at the five P’s, you know, the pertinent history, the predisposing factors, the precipitating factors? 

Previous treatment and response and positive factors. In addition to their presentation and so taking all of the information and then kind of listing it out into these separate areas will give us a clinical snapshot of what we’re looking at, and especially if we have to do a case presentation or if you’re handing off this case to someone else. 

It’s a really helpful way to kind of paint a picture for somebody else so they whoever is picking up the case gets a quick idea of what the needs are, what the struggles are for the client, and that will help prime the other clinicians mind or the psychiatrist’s mind. 

Of how to proceed mindfully with this with this client right? And that’s really doing the client’s service, because we’re advocating for them even in the way that we document the assessment. OK, it’s not like somebody else has to start from scratch, right? 

Or dig through a body of text to kind of get a feel for what’s going on, right? 

So the presentation is kind of like we started off with at the top that we talked about. This is their their age, gender, orientation, ethnicity. 

Marital status. Do they have kids? And then of course, how do they present? Do they present somebody with a lot of insight? Do they present with somebody or as somebody who is a good historian? Do they have a linear thought process or are they very disorganized? Are they put together then well groomed, or they disheveled? You know, these are things to pay attention to. 

If there is any in congruence with their stated mood, and so a lot of the presentation ties into the mental health status exam, are they orientated to time person, place, situation? 

Are they having any internal stimuli? Are they? Does it look sound like there? It looks like they’re responding to any auditory hallucinations or visual hallucinations. These are definitely things you want to kind of tease out. And then of course their interaction styles. This person really easy to talk to, or are they very guarded? You know this person. 

Suspicious or paranoid? Or is this person love to talk a lot? Where? What is their style? Or are they storytellers is it? 

Does it take a lot of time to engage this person because they like to share a lot or is this somebody that you have to tease a lot of information out of? Those things are important. 

So again, this is not the history they’re presenting problem, right? There are predisposing factors, so this could be something like history of mental illness in the family. This could be in environmental situations, the way they’re raised, particular neighborhood, family dynamics was. 

Were they raised in families, heavily entrenched in gangs, those things are all relevant precipitating factors this is. 

Something that speaks to recent situations that lead them to mental health treatment. So oftentimes the question is why now? 

So you’re seeking mental health services, but why now? Why not before? Why not last year? Especially if this is the first time we really want to have a clear idea of what’s going on. 

That you’re now asking for help. What just happened to you? You know what was the hair that broke the camels back, right? Or or? Are they just being proactive, right? Maybe they’re really good with that, and they’re really good about asking for help before things become a big problem, right? That would also be a strength, and we also want to see in terms of perpetuating factors. 

Things that are currently contributing to their stress. Remember that section with the contributing stressors contributing factors? That’s what we’re talking about, so we want to find out what’s keeping them stuck. 

What’s keeping them unhappy? So this is often times where you would ask the miracle question. You know if you woke up tomorrow. 

And a miracle happened. How would you know what would be different so it’s that whole idea of solution focused therapy, right? Is that you’re trying to find the exception. So if life stinks right now, what would like what would life look like if it didn’t stink right? What would be different? And then that often will. 

Exactly what is weighing on the client, what the perpetuating factors are OK. 

And then positive factors. This is the strength, right? This is the strength and also things that maybe they didn’t identify your strengths that we see just and interacting with this person. And this person has really good insight or this person is really motivated to get help or this person is really well spoken, you know. Or this person hasn’t really solid goals in a clear plan about what they want to do. 

“This person is really artistic”. You know, these are things that we want to be able to list out in their own categories so that we can leverage them during treatment. OK.

Identified. Needs; you know, this is very, very tangible, so this is a very practical stuff, so I’m going to say like, oh, this person needs a primary doctor. 

This person has not had a physical in 10 years. It might be this person is homeless, right? They need housing or they need more appropriate housing or different housing environment, right? 

It could be something. 

Like 

This person needs to work on our communication skills. They bottled everything up. They contain everything and that’s why they explode. Or that’s why they get depressed is ’cause they’re not expressing themselves, so they don’t know how to communicate or they share too much right? They don’t know how to have good boundaries, and so these are things that we want to work on, right? Interpersonal effectiveness. 

Target behaviors; these are more specifically not just needs in terms of their quality of life, but the biggest red flags like this could be self interest behavior. This could be substance use. This could be anger outbursts. You know these are the target things that we’re most likely going to address in our treatment plan. 

All right, and so the DDX, the differential diagnosis is the last piece here, and this is really where we’re trying to use all of the information we just gathered, this is where we are really trying to determine what our clinical impression is.

This could be a few different things. This person could be going through an adjustment disorder, or maybe it’s an acute anxiety, or maybe as panic disorder. Or maybe it’s a major depressive disorder and maybe it’s a bipolar disorder. You know, this is where we’re trying to like say this versus this versus this, and based on all of the information presented. 

And all the information we have at hand, anything documented and our clinical impression. This is the provisional diagnosis that we’re giving them as our first impression. But keeping in mind that a diagnosis is not fixed, a diagnosis is nothing more than impression. It’s a compass that says, OK, this is what we think is going on, and so this is what we’re going to focus on right now in terms of the treatment plan and where where our head is at in terms of what we think the problem is. 

But that could change, right? Somebody could present as depressed, but we’ve you know they have a manic episode, you know, six months later and we found it, oh, so it’s not just depression as a bipolar disorder. Well, that changes things, especially with regard to medication, right? 

But understanding that a diagnosis is a living document, it’s not fixed and often times if you look at somebody’s history, they’ll have sometimes 10 different diagnosis because they present to different providers in a different way, different circumstances, and so that paints a very different clinical impression. Alright, OK? 

Plan

And so then, once you’ve got all that built out in the assessment, after you’ve done your formulation, this is where I like to list out the plan, because especially ’cause I don’t even know if I’m going to be keeping a case or if it’s going to go with someone else. 

But the plan is important in terms of case, So what happens next? So we’ve done the assessment. We’ve identified our clinical impression. We’ve got a background, got a diagnosis. 

This now we need to kind of think about. OK, So what happens next? And so who’s getting the case? Let’s say the case is being activated with, you know who is it going to? Am I going to keep the case? Is it going to another clinician? 

A caseworker, drug and alcohol counselor, a housing specialist and employment specialist. You know it’s important to know. 

Who’s going to be moving forward with the client? Medication support services? You know this may not be relevant. Maybe they they have no need for medication or no desire for medication. But if they do have a medication need that’s not being met, we definitely want to address that. So that might look something like, you know, the client is going to be scheduled with the psychiatrist and this is their appointment date. And in the meantime. 

I have encouraged the client to go to this mental health urgent care over here in order to get started on medication in the interim and so. 

We want to be sure that we’ve been very clear about what our plan is with the medication. If we’ve identified that as a need, OK, Now the PHQ-9 and the GAD-7 these are known as outcome questionnaires, right? They’re used as a way to get a baseline score. 

For specific symptoms, so the PHQ-9 is an outcome measure designed for depression is the Patient Health Questionnaire. This is used pretty regularly now in medical offices, primary care, mental health. 

And it’s a way to kind of flag potential, major depressive disorder, and it’s, you know, different symptoms. And it gives us a score out of 27 and generally anything North of #12 is a little concerning anything North of #18 is very concerning, and so this just kind of gives us a baseline of what to look for and also specifically what symptoms are the most distressing and then that can also really inform the treatment plan, which is why I use it a lot for something with add seven that stands for general anxiety disorder and so a lot of the questions are geared toward, you know, is this person have a general anxiety or not, or was specific symptoms of general anxiety disorder causing them the most distress? And that’s based out of #21 points, and so again, just like the PHQ-9, it’s more of a. 

A way to inform us of you know what to focus on and then overtime we want to see that score coming down OK and so. 

I know I’m I’m creating this tutorial. 

Parceled out you know in the clinical loop but in real time we would be doing the assessment in the treatment plan together, right? You want to do the treatment plan at the same time you’re doing the assessment, ideally, and not to let it tail behind too much, especially when it’s fresh in your mind and you have the client in front of you were on the phone or video and you really have them in that frame of mind. You want to say so. We talked about all these things so. 

What is it that you would like to see happen? And so the treatment plan will consist of, like a long term goal and short term objectives and we’ll talk more about that in Part 2 of the clinical loop when we discuss the treatment plan OK, and that will be the next episode. And then of course, you want to make sure that all of your consents are done, not just consent for treatment. 

But consents for any other relevant parties so primary care provider, family, anybody else that might be involved. DCFS probation officer? Anybody that might have? 

An interest with the client wants them to be involved in treatment, and you can specify of course the different levels of involvement, but it’s important to make sure those are all done ’cause it’s really a pain to get those later if you need to. Sometimes it just slows down the treatment process OK, and then of course any referrals you want to list out too. 

Identified needs. Like I said, this could be a mental health. Urgent care for medication, suicide hotlines, always a good one to give out any peer support hotlines. 

Substance abuse hotlines, that kind of thing. If you do give out any resources you want to be sure to kind of list those out. If for nothing else for a reminder an. 

So. 

This is often the way I do an assessment, I’m not writing the assessment just for it to look pretty. I’m I’m writing the assessment for myself because I want to be able to look back on my own notes, my own assessment, and be able to know exactly where my head was at. Because in the mental health world you know we see so many people, it’s it’s easy to kind of forget about the minutia of what was discussed, and so if you write a good assessment and it doesn’t have to be that way. 

You know, just lengthy for the sake of being lengthy, but if you have that vital information in there and it’s it’s summarized well it makes it a lot easier for you to reflect on your assessment when you’re about to see a client like, Oh yeah, that’s right. These things are really important. I want to make sure we put this into the treatment agenda so we don’t miss this because this was so important when they talked about it and you’re not the only one who’s going to forget about it. The client forgets also. 

The client will forget what they discussed week to week or session to session or the intake. You know, when you had opened everything up and so it’s really doing the client of service. If you’re able to reflect on those highlights and tease those things, back out, circle back to them. You know, during treatment, during progress notes or sessions and. 

Make sure that your documenting it, revisited these things because it will keep you on point as well. OK, so it’s a win win.

Well, I hope that was helpful. I know it was a lot. Certainly could have gone through this in more detail, but I am trying to keep this brief and write an helpful. 

So if you found it helpful, please do be sure to like and subscribe via YouTube, or if you are listening to this on the podcast and be sure to register with the MHT Newsletter to be notified of any new content as it is published.

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Learn more at www.thementalhealthtoolbox.com. 

NEED CRISIS HELP? If you need immediate crisis help with your depression, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741

OUTSIDE THE UNITED STATES: See International Suicide Hotlines

WHERE TO FIND MENTAL HEALTH HELP:
-NAMI Referral Helpline: 1-800-950-6264

-California’s Statewide Mental Health Helpline: 1-855-845-7415