Initial Intake Assessment Mental Health: Fill & Download for Free

Great question!If it’s done correctly, some version of the following steps should occur.Initial consultation to determine counselor-client fit.Intake assessment: A semi-structured assessment that includes things like past history, nature of presenting problem, medical status, family of origin issues, risk assessment, cultural assessment, and mental status examination.Collateral information collection (from family, friends, etc., if the client agrees to it), or screening instruments or - especially in the case of personality disorders - formal psychological assessments, scored and interpreted.Confidential consultation with another qualified professional with expertise in personality disordersReview and elimination of differential diagnoses (ruling out what else it could possibly be)Write up of diagnostic impressions and rationale for diagnostic formulationWillingness to reassess as counseling continues and new information comes to light or it becomes clear the clinician missed or misunderstood something important and their initial diagnostic impression no longer accurately explains what is going on.Some important considerations when diagnosing personality disorders is that most of them are highly stigmatized in U.S. American culture, so formally diagnosing one is a very powerful statement. This requires some humility on the part of the diagnosing clinician, both in willingness to seek consultation and go through the differential diagnostic process EVERY SINGLE TIME, and in a willingness to admit a mistake if they get it wrong. Or, perhaps even assume there is a possibility of error and plan on revisions as counseling ensues.Another important consideration is that our (U.S. American) understanding of personality disorders is a little behind. Meaning, our research wasn’t adequate for many revisions between the DSM-IV-TR and the DSM-5, and some expected changes, like the addition of C-PTSD and the resulting reduction in prevalence of BPD didn’t occur. So, it’s especially important to remain open minded when diagnosing a perceived personality disorder and consider that answer from all angles, and be humble enough to revise the conclusion if necessary.

A good way to assess your therapist’s behavior, if it seems inappropriate, and you aren't comfortable discussing it with them, or no longer see them as reliable/trustworthy, is to have a look at their professional code of ethics. These are slightly different, depending on their licensure—so if you know whether they're licensed as a psychologist, professional counselor, social worker, marriage and family therapist, mental health counselor, addictions counselor, or something else, that will help you track down the relevant document. Professional ethics are posted on the websites of all of our national associations—for me as a marriage and family therapist, for example, if you search “marriage and family therapist professional ethics,” you’ll get a link to the AAMFT website, with a comprehensive listing of ethics, and some clarifying information about each standard.You can also usually look up relevant legal standards on the website for your state mental health regulatory board. This may be a little trickier to hunt down. In my state, we have one overarching organization that regulates all non-medical mental health professionals. In some states, it’s divided further by specific profession or licensure, or rolled into some larger governing body. If you search “[your state] mental health licensing board,” you can probably find it that way. Usually, it will feature links to the statutes governing mental healthcare in your state.If it's clear that your therapist violated one or more of the laws or professional ethical standards that apply to them, you have your answer. At that point, there are several steps you can take, and I'll talk about those in a moment. If it's unclear to you, or if it appears that they haven't broken any rules, but something still feels wrong, it might not be a bad idea to get a second opinion. This could come from their work supervisor or clinical supervisor, if they have one; or you could consult with a different mental health professional, a healthcare consumer advocate, or a peer counselor, to get their perspective. You could also look for feedback from a friend or family member; bear in mind, though, that they may have their own biases for or against the idea that your therapist has treated you abusively. No matter who you talk to—at the end of the day, you are the person who gets to decide whether to continue the clinical relationship, and how to follow up outside it. It is okay to leave therapy just because you feel uncomfortable or unsafe—there’s not a specific minimum standard you have to meet, to decide it isn't a good fit, and it's time to move on.If you either feel certain that your therapist behaved abusively, inappropriately, and/or unethically; or you really aren't certain, and can't make sense of it one way or the other, it is a good idea to make a report. While responding to a governing board complaint can be a headache—it is also something that all of us sign on for, just by being therapists. It's an important way to get some relatively impartial, experienced and professional eyes on problematic professional behavior. And it is often a necessary part of protecting public safety and therapist integrity.Be mindful that if you file a complaint, you will generally be asked to sign a release to the board, granting them access to your clinical records. Governing boards are usually made up of mental health professionals, themselves; this doesn't mean your personal information will be trumpeted from the mountaintops—but they do need to see that information, to fully understand what happened, and intervene appropriately.Most state licensing board websites will have a link to a complaint form, which you can either fill out online, or print and mail in. If not, you can give them a call, and ask how to initiate this procedure.You can also look into filing a complaint with a national professional organization. While these don't have direct control over therapist licensure, they do have the ability to rescind membership which, in most states, will automatically take away a therapist’s license. So they can impose censures, sanctions, and requirements for continuing education or re-training.And—assuming your therapist works in a larger practice, and/or under clinical supervision (you should have been told at intake, if they do); you can call their boss. This might lead to a higher-pressure sell about reporting to a state board; in and of itself, though, it is likely to be the lowest-stress option for you.Last but not least, you can seek legal counsel. Depending on what happened, this might be more of a legal charges or civil charges thing—or both. I'm not a lawyer, so I'll refrain from guessing; but a good starting point in that case would be to call your local Legal Aid organization for advice about next steps.

As a psychologist, I am required by good clinical practice, the regulations of the insurance companies for which I am a credentialed provider, and, in some cases, state laws, to take contemporaneous notes of all of my contacts with my patients. I also need contemporaneous, written documentation in case I am ever accused of any wrongdoing. More importantly, the treatment orientation that I use employs lots of homework and focuses on the process of therapy and measuring the patient’s progress in treatment. I also initiate therapy with an intake assessment that is written, sometimes with psychological testing, and a treatment plan, all of which are memorialized as written documents.I use the time between sessions to document the session I’ve just had with a patient using a format I developed years ago to make the process easier than writing up the whole session and to review my chart for the arriving patient.Because I have documented information that I have reviewed about a patient before they come in as well as a plan for treatment, I usually don’t forget about details that we talked about previously. It is unfair to clients to forget about things they’ve revealed to me because they felt that the process and the information was important enough to disclose to me.I do know what I think you may be referring to though. My younger son has an autism spectrum disorder, fetal alcohol spectrum (he was adopted as an infant and abused the first 7 months of his life before he came to live with me), bipolar spectrum disorder, and a few other significant psychiatric disorders. I have attended many sessions with him with a broad range of mental health professionals of varying skill sets. Even with notes it seemed that one psychiatrist could not keep up with what was going on for him. I was glad when we met and he began treatment with a very well-known pediatric psychiatrist who was excellent. Sometimes it would seem like a particular clinician was totally clueless as to what had gone on a week ago. We changed therapists often for a while. That level of not preparing for a session is just a lack of clinical skills. I can make allowances for many things but my child’s health is a non-negotiable.