Psychiatry
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This is a dual signature report. My supervising clinician is Cindy Morey, Psy.D., ABPP, MBA, LP.

Date of service: [date name="DAdate" default="today"]
Duration: 1 hour ([text name="DAstart" default=""] - [text name="DAend" default=""])

Format:
[checkbox name="inperson" value="Therapy was provided in person at Kai Shin Clinic.|Teletherapy was offered in lieu of in-person treatment due to: COVID-19 social distancing. Risks and benefits of teletherapy were provided and client gave verbal consent to continue.|This session was provided via Doxy.me, HIPAA-compliant video telehealth software.|This session was provided via telephone as the client is unable to access video teletherapy software at time of today's session."]

This is a [text name="DAtype" default="standard diagnostic assessment"]. In addition to diagnostic interview, contributions to this assessment include:
[checkbox value="The client's medical records from Kai Shin Clinic"]
[text default=""]

Informed Consent:
The purpose, benefits, and risks of psychological assessment and treatment were reviewed. The client agreed to proceed. The client was able to participate and benefit from treatment as evidenced by his/her verbal expression and understanding of ideas discussed.

----------

Referral source and reason for referral:
The client was referred by [text name="referent" default="Dr. "] for [textarea rows="1" default="the evaluation of mental health symptoms"].

[text name="name" memo="Client name" size="20"] is a [text memo="age" size="3"]-year-old, [select value="single|married|partnered|"] [text memo="ethnicity" size="20"] [select value="cis-gender female|cis-gender male|transgender woman|transgender man|gender non-binary individual"][text default=""] who [select value="lives in a sober home|lives with their significant other|lives with their family|lives alone|is homeless|is homeless living with a friend|is living in a shelter|lives with their parents|lives with their children|lives with a roommate|lives with roommates"][text name="livingother" default=""] in [text name="location" memo="residing location" size="20"]. [textarea rows="3"]

Presenting problem:
The client presents in this outpatient appointment [select value="alone|with family|with significant other|with case manager"][text size="20"] [select value=" for evaluation of|due to reports of|"][text memo="presenting problem" size="20"]. [select value="The client reports|The family reports|The case manager reports|Medical records indicate|"] [select value="a past history of |no history of mental health concerns until |no history of mental health concerns|"] [textarea memo="history of presenting concern" rows="5"]. The client reports historical diagnoses include: [text default=""]

Services sought and expectations:
[textarea rows="2"]

Other factors contributing to presenting concerns:
[textarea rows="1"]

How do you perceive your condition compared to how others perceive your presenting concerns:
[textarea rows="1"]



----------

REVIEW OF SYSTEMS:

Depressive Symptoms:

[checkbox value="none reported|sad mood|dysphoric mood|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|difficulty falling asleep, w/ delayed onset of sleep up to 1 hour|difficulty falling asleep, w/ delayed onset of sleep of 1 - 2 hours|difficulty falling asleep, w/ delayed onset of sleep greater than 2 hours|middle of night awakening|early morning awakening|moving or speaking so slowly that other people could have noticed|daytime fatigue|loss Of appetite|increased appetite|difficulty concentrating|decreased attention|increased anxiety|ruminative thoughts|feelings of worthlessness|excessive guilt|thoughts of death|mood symptoms are persistent and pervasive, varying little from day to day|depressed mood/sadness most of the time for 2-years or longer "].
[textarea rows="1"]


Manic Symptoms:

[checkbox name="mansx" value="none reported|endorses bipolar diagnosis but no current symptoms reported|distinct period of abnormally and persistently elevated, expansive or irritable mood|accompanied by persistently increased goal-directed activity or energy|mood disturbance and increased energy/activity has lasted at least one-week and is present most of the day, nearly every day|mood disturbance and increased energy/activity has lasted at least 4 consecutive days and is present most of the day|pressured speech|inflated self-esteem|grandiosity|decreased need for sleep|hyperverbosity|flight of Ideas|subjective racing thoughts|distractiblity|psychomotor agitation|high risk activities| Denies behaviors occurred solely in the context of substance abuse.| Reports majority of sx occurred in the context of substance abuse."]
[textarea default=""]


Anxiety Symptoms:

[comment memo="GAD"]
[checkbox value="none reported|Excessive worry occurring more days than not|Difficulty controlling worry|Muscle tension|Fatigue|Difficulty concentrating|Restless or feeling on edge|Irritability|Sleep disturbance|Symptoms for at least 6 months"][textarea rows="1"]
[comment memo="Panic"]
[checkbox value="recurrent unexpected panic|Palpitations, racing heart|Sweating|Trembling or shaking|Shortness of breath or smothering|Choking|Chest pain or discomfort|Nausea or abdominal distress|Feeling dizzy, unsteady, light-headed or faint|Chills or heat sensations|Numbness or tingling|Derealization or depersonalization|Fear of losing control|Fear of dying|Fear of another panic attack occurring|persistent worry about the implications of the attack|change in behavior because of the panic attacks"][textarea rows="1"]
[comment memo="Agoraphobia"]:
[checkbox value="Fear of using public transportation|Fear of public spaces|Fear of enclosed places|Fear of standing in line|Fear of being in a crowd|Fear of being outside the home alone|Situations are avoided or endured with marked distress|Thoughts that escape might be difficult|Thoughts that help might not be available|Thoughts that symptoms might be incapacitating or embarrassing|Avoidance of these situations|Fear or avoidance lasts 6 months or longer"][textarea rows="1"]
[comment memo="OCD"]
[checkbox value="Unwanted ideas, images, or impulses that seem silly, nasty, or horrible. |Excessive worry about dirt, germs, or chemicals. | Excessive washing or cleaning. | Compulsive checking. |Fear that something bad will happen because of a forgotten action.| Fear of acting or speaking aggressively when doesn't want to. | Always afraid will lose something of importance. Compulsive behaviors or thoughts to ease anxiety. |Keeping many useless things because feels can't throw them away."]
[textarea rows="1"]

PTSD Symptoms:

[checkbox value="none reported|Experienced traumatic event|Recurrent distressing memories|Flashbacks|Upsetting dreams|Emotional reactivity to reminders|Physical reactivity to reminders|Avoiding stimuli associated with the event|Avoiding thinking or talking about event|Negative beliefs about self|Negative beliefs about the world|Hopelessness about future|Unable to remember important parts of the traumatic event|Memory problems|Detachment or difficulty maintaining close relationships|Diminished interest in activities|Difficulty experiencing positive emotions|Emotional numbness|Sleep disturbances|Irritability|Feeling on guard|Self-destructive behavior|Difficulty concentrating|Hyper-vigilance|Exaggerated startle response|Irritability or angry outburts|Overwhelming guilt or shame|Symptoms lasting at least 6mo"]
[textarea rows="1" default="Denies any current or past history of post-traumatic symptoms"]

Psychosis Symptoms:

[textarea default="Denies any current or past history of psychotic symptoms."]

Cognitive Symptoms:

[checkbox value="No history of head injuries or traumatic brain injuries. |History of traumatic brain injuries resulting from |Underlying cognitive impairment from |"][textarea rows="1" default="Denies any current or past history of cognitive symptoms"]


ADHD:

[checkbox name="variable_1" value="Can't organize tasks|Loses things needed for tasks|Has problems finishing tasks|Poor focus|Easily distracted|Doesn't listen|Forgets easily|Makes careless mistakes|Avoids tasks requiring concentration|Talks too much|Blurts out answers|Interrupts others|Can't play quietly|Fidgets and squirms|Leaves seat|Restlessness|Always on the go|Can't wait for their turn|Some symptoms present before the age of 12|Symptoms occur in 2 or more settings"]
[textarea rows="1" default="Denies any current or past history of ADHD symptoms"]

Sleep:

[checkbox value="Difficulty initiating sleep |Difficulty staying asleep |Problems with early waking |Confirmed apnea |Suspected apnea|Chronic pain|Restless leg syndrome|Anxiety before bed"]
Sleep is reported to be generally [select name="sleepq" value="poor |fair |good |erratic |inconsistent |excessive"]
[textarea rows="2" default ="The client estimates getting approximately ? hours of ? sleep per night."]

Eating Disorder:
[textarea rows="1" default="Denies any current or past history of eating disorder symptoms"]

Other:  
[textarea rows="1" default="None noted"]

Substance use:

CAGE-AID
[checklist value="Felt ought to cut down|Annoyed by criticism of use|Felt bad or guilty about use|Eye-opener to steady nerves or get rid of hangover"]

[textarea default="The client identifies substance of choice is ."] Endorses
[checkbox value="Impaired control|Persistent desire to quit|Excessive time|Craving|Role failure|Social problems|Reduced activity|Physical problems|Psychological problems|Tolerance|Withdrawal"]
[textarea rows="1"]

[select value="Endorses tobacco use consuming approximately |Endorses past history of tobacco use but quit approximately |Denies any tobacco use|"][textarea rows="1"].

Other Problem Behavior(s):

[checkbox value="During past 12 months|Restless, irritable, or anxious when trying to stop or cut down on gambling|Tried to keep family or friends from knowing how much you gambled|Financial trouble from gambling that needed help from family, friends, or welfare"]
[textarea rows="1"]

----------

Suicidality/self-harm/homicidality:

[select value="The client denies access to guns|The client endorses access to guns"][textarea rows="1"]. [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that the client is unsafe to self or others, provider and the client will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

Suicidality: [checkbox value="[select value="Denies current ideation, plan, or intent|Endorses past ideation only|Endorses past ideation and plan only|Endorses past ideation, plan, and intent|Endorses previous attempt|Endorses multiple attempts|Endorses current ideation, Denies current plan or intent|Endorses current ideation and plan, but denies current intent|Endorses urrent ideation, plan, and intent|The client is able to contract for safety. |The client denies being able to contract for safety."][textarea rows="1"]

Self-injury: [textarea rows="1" default="Denies history of self-harming behaviors"]

Homicidality/bodily injury towards others: [checkbox value="Denies current ideation, plan, or intent|Endorses past ideation only|Endorses past ideation and plan only|Endorses past ideation, plan, and intent|Endorses previous attempt|Endorses multiple attempts|Endorses current ideation, Denies current plan or intent|Endorses current ideation and plan, but denies current intent|Endorses urrent ideation, plan, and intent"] [textarea rows="1"]

----------

HISTORY:

Past Psychiatric/Chemical Dependency History:

[select value="Previous psychiatric medication trials include but may not be limited to: |The client reports no history of taking psychiatric medications|The client is unable to recall past psychiatric medication trials|"][textarea rows="1"]. [select value="There is no history of psychiatric hospitalizations|Psychiatric hospitalization history includes |"][textarea rows="1"]. [select value="Previous psychotherapy/counseling services includes |The client reports no history of psychotherapy/counseling|The client reports history of psychotherapy/counseling in acute/residential treatment settings only"][textarea rows="1"].

Past treatment for substance use includes [checkbox value="detox|hospital inpatient|residential treatment|outpatient treatment|counseling|anti-relapse medications"]. [textarea rows="1" default="There is no history of treatment for gambling"]

[select value="Current psychiatric medications include: |The client is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with the client due to symptomatic presentation|"][textarea rows="4"]. [select value="The client plans to meet with writer for counseling/therapy. | The client is not currently receiving individual counseling/therapy |The client is currently engaging in individual counseling with |"][textarea rows="1"].

Past Medical History:

Allergies: [text size="20" default="None"]
Current medications: [textarea rows="1" default="No medications for medical issues."]
[textarea rows="1" default=""]
Primary care: [text size="20"]
Last physical: [text size="20"]


Past Family Psychiatric History:
[select value="There is no known family history of mental illness|Family history of mental health problems is positive for ||"][textarea rows="1"]. [select value="There is no known history of suicides or self-harm in the client's family|Family history of suicides/self-harm includes ||"][textarea rows="1"].

Past Family Medical/Physical History:
[select value="There is no known family history of medical issues|Family medical history is positive for ||"][textarea rows="1"].

Past Family Chemical Dependency History:
[select value="There is no known family history of substance use issues|Family history of substance use is positive for ||"][textarea rows="1"].

Cultural impact on health and healthcare.

Health beliefs and engagement in cultural specific healing practices (describe the client's physical health sxs/diagnosis and use of traditional rather than western medical practices in treating illness):
[textarea rows="1" default="The client prefers Western medical practices."]


SOCIAL HISTORY:

[comment memo="placements, multiple Moves While Growing Up, change in family composition, socio-economic status, lifestyle, exposure to fam conflict/violence, major illness, loss of fam/friends, loss/separation, Change in School. abuse"]

[textarea rows="10" default=""]

[comment memo="Did mother use alcohol, cigarettes, drugs? Illness/accidents/stressors during pregnancy, motor skills, speech, sleep, eating, separation, attachment"]
Important Developmental Incidence: [textarea rows="2" default="The client's birth reported as unremarkable. Developmental milestones were reportedly reached at age-appropriate times."]

[select value="There is no history of trauma|The client endorses history of trauma but did not want to elaborate|The client reports past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="1"].

School/Work History:

The client's level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"]. [select value="The client reports no military history|Military history includes |Military history was not addressed this visit. |"][textarea rows="1"]. [textarea rows="3" default=""]. The client is [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently unemployed due to participation in treatment|currently employed full-time|currently employed part=time|working overtime|not formally employed but working odd jobs|currently retired from |"][textarea rows="1"]. Financially the client [select value="reports no immediate concerns|reports financial stress due to healthcare costs|has concerns related to supporting their family|"][textarea rows="1"]. The client's source of income is primarily [select value="disability|social security|unemployment|current employment|family support|county benefits|"][textarea rows="1"].

Current Living situation: [select value="in sober housing|alone|with significant other|with significant other and children|with children|with extended family|with parents|"][textarea rows="1"]. [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="2"].

Sexual Orientation: [select value="|heterosexual|homosexual|bisexual|pansexual|asexual|was not addressed this visit"][textarea rows="1"].

Marital/relationship History: Currently [select value="married|partnered|engaged|single"][textarea rows="1"]

Evaluation on quality of relationships: [textarea rows="1"]

Social Network/Support Systems/Hobbies & Interests: The client identifies [checkbox value="having no one|significant other|parents|children|siblings|extended family|friends|peer supports|treatment cohort|church members"][text size="20"] as social support network. The client has [select value="0|1|2|3|4|5|6|7|"] children[text size="20"]. The client's hobbies/interests include [textarea rows="1"].

Strengths/Personal/Community Resources: The client reports personal strengths as: [textarea rows="1"]. The client reports other resources include [textarea rows="1" default="medical providers at Kai Shin Clinic"].

Spirituality/Belief systems: [select value="Christian|Catholic|Muslim|Jewish|Traditional Native American|Personal spirituality|Athiest|Agnostic||Not addressed this visit|"][textarea rows="1"].

Cultural Identification:
Race/ethnicity: [select value="Hispanic |Non-Hispanic "][select value="|White|Black|Native American|Asian|Pacific Islander"][text size="20"]
Experience of cultural bias: [text size="20" default="N/A"]
Immigration/history of status: [text size="20" default="N/A"]
Level of acculturation: [text size="20" default="N/A"]
Time orientation:  [text size="20" default="past/present/future-focused"]
Social Orientation/class: [text size="20" default="N/A"]
Verbal Communication Style/languages: [text size="20" default="English"]
Locus of Control: [select value="internal|external|"][text size="20"]

Family Involvement: Is the family involved in the diagnostic assessment and process? [text size="4" default="No"]
If so, their agreement to referrals and follow-up plan: [textarea rows="1" default="N/A"]

LEGAL HISTORY:
[comment memo="arrests, offenses, tickets, warnings, probation, incarceration"]
[select value="No current legal concerns|Legal concerns include |The client endorses legal history but declines to elaborate|"][textarea rows="1"].

Problem List:
[textarea rows="1"]






SCREENING SCORES

WHODAS 12 item: [text default=""] [link url="https://docs.google.com/spreadsheets/u/1/d/1gHz6hRoVqrG5gAhQSzKDEYFcSP_cI0UDWkiqKj8SDHc/edit#gid=1825755498" memo="calculator"]
GAIN-SS: [text default=""]
ASRS [text default="not administered"] [link url="https://www.mdcalc.com/adult-self-report-scale-asrs-adhd" memo="calculator"]
GAD-7 [text default="not administered"] [link url="https://www.mdcalc.com/gad-7-general-anxiety-disorder-7" memo="calculator"]
PHQ-9 [text default="not administered"] [link url="https://www.mdcalc.com/phq-9-patient-health-questionnaire-9" memo="calculator"]

MENTAL STATUS EXAMINATION:
Reliability: Appears to be a[text default="n adequate"] historian
Alert and Oriented: [select name="oriented" value="x4|x3|x2|x1"]
Appearance: [select name="appearance" value="Appropriately dressed/well groomed|disheveled|inappropriately dressed|neglected"].
Attitude toward the interview: [select name="attitude" value="cooperative|guarded|suspicious|paranoid|paranoid|warm"].
Eye contact: [select name="eyecontact" value="Good|Fair|Poor|Fleeting|Avoidant|Not applicable - telephone session"].
Psychomotor activity: [select name="psychomotor" value="none|agitation|retardation"].
Speech: [select name="speechrate" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous|slow|loud|soft"].
Thought process: [select name="thoughtprocess" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous|word salad"].
Thought Content: [select name="thoughtcontent" value="absence of delusional or obsessional thinking|delusion|guilty|future oriented|fears|ruminative ideas"].
Mood: [select name="msemood" value="euthymic|neutral|anxious|dysphoric|apathetic|depressed|hypomanic|manic|irritable|mixed"][text name="mood" default=""]
Affect: [select name="mseaffect" value="congruent with mood, stable|blunted|flat|labile|restricted|incongruent with mood"].
Perception: [select name="perception" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preoccupied with delusions|preoccupied with thoughts"].
Suicidal Ideation: [select name="suicidalideation" value="none present|passive ideation, no plans or intent|actively suicidal"].
Homicidal Ideation: [select name="homicidalideation" value= "absent|current homicidal ideation"]
Insight: [select name="insight" value="fair|good|poor"].
Judgment: [select name="judgment" value="fair|good|poor"]
Cognition/Memory: [select name="cognitionmemory" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="cognitionabstraction" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]



MEDICAL NECESSITY:

Is the client's impairment in functional capacity the result of a mental/emotional disturbance? [checkbox value="Yes|No"]
Does the client's mental/emotional disturbance significantly impair their functional capacity within an important area of life functioning? [checkbox value="Yes|No"]
Does the client's mental/emotional disturbance create for the probability of significant deterioration in an important area of life functioning? [checkbox value="Yes|No"]
Does the client's mental/emotional disturbance create for the probability that they will not progress developmentally as individually appropriate? [text default="Not applicable"]
Is the client's mental/emotional disturbance a condition which specialty mental health services could correct or ameliorate? [checkbox value="Yes|No"]
Given the nature of the functional impairment noted above, treatment services will significantly reduce and/or prevent significant deterioration in functioning, and because of that, the following domain/domains of functioning will be treated: [checkbox value="cognition|mobility|self-care|getting along|life activities (household and work)|participation."][textarea default=""]

RISK:

The client is currently assessed to be at [select value="no|low|moderate|high"] risk for self harm or suicide as evidenced by [text default="the client's self-report of not having any suicidal ideation, and/or plan, and/or intent based upon today's interview."] The following action was taken as a result of the client having a suicidal ideation/plan/intent:[text size="20"default="No action taken."]

The client is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by [text default="the client's self-report of not having any homicidal ideation, and/or plan, and/or intent based upon today's interview."] The following action was taken as a result of the client having a homicidal ideation/plan/intent: [text size="20" default="No action taken."]


CLINICAL FORMULATION:

The client is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"].

The client would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|continued participation in substance use diosrder treatment|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"].

Prognosis is [select value="good|fair|poor|guarded"] considering the client [select value="remains adherent to|actively engages in|is not currently responding to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and ability to engage constructively with social supports."]

Barriers to success include [checkbox value="current apprehension to engage in psychiatric intervention|current apprehension about anti-relapse medications|current apprehension to engage in structured substance use treatment|current apprehension to engage in psychotherapy|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight|limited coping skills"][textarea memo="barriers" rows="1"]. The client's strengths for success include: [checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment|good insight|high intelligence"][textarea memo="strengths" rows="1"]. [textarea rows="5"]. [textarea default="If the client's mental health issues remain untreated, the client will continue to struggle with impairments in relationships, employment, and lifestyle, placing the client at an increased risk of hospitalization, criminal justice involvement, and relapse."]

CLINICAL DIAGNOSIS:
Based upon the client's reported symptoms, the client meets criteria for DSM-5:
[textarea rows="3"]



FOLLOW UP PLAN:
[textarea default="1. Writer recommends the client participate in individual therapy. This writer will meet with the client as appropriate in order to initiate and continue psychotherapy services.
2. Writer recommends client continue with addiction medicine and psychiatry services, in order to address mental health and substance use disorder symptoms."]

Provider Name: Emily Iwuc, MPS, LADC
Signatures:Service Performed and documented by: Emily Iwuc, MPS, LADC
Supervising Clinician: Cindy Morey, Psy.D., ABPP, MBA, LP
I have read, discussed and agree with the documentation provided by Emily Iwuc, MPS, LADC.
Cindy Morey, Psy.D, ABPP, MB., LP
This is a dual signature report. My supervising clinician is Cindy Morey, Psy.D., ABPP, MBA, LP.

Date of service:
Duration: 1 hour ( - )

Format:


This is a . In addition to diagnostic interview, contributions to this assessment include:



Informed Consent:
The purpose, benefits, and risks of psychological assessment and treatment were reviewed. The client agreed to proceed. The client was able to participate and benefit from treatment as evidenced by his/her verbal expression and understanding of ideas discussed.

----------

Referral source and reason for referral:
The client was referred by for.

Client name is a age-year-old, ethnicity who in residing location.

Presenting problem:
The client presents in this outpatient appointment presenting problem. history of presenting concern. The client reports historical diagnoses include:

Services sought and expectations:


Other factors contributing to presenting concerns:


How do you perceive your condition compared to how others perceive your presenting concerns:




----------

REVIEW OF SYSTEMS:

Depressive Symptoms:

.



Manic Symptoms:





Anxiety Symptoms:

GAD

Panic

Agoraphobia:

OCD



PTSD Symptoms:




Psychosis Symptoms:



Cognitive Symptoms:




ADHD:




Sleep:


Sleep is reported to be generally


Eating Disorder:


Other:  


Substance use:

CAGE-AID


Endorses



.

Other Problem Behavior(s):




----------

Suicidality/self-harm/homicidality:

.

Suicidality:

Self-injury:

Homicidality/bodily injury towards others:

----------

HISTORY:

Past Psychiatric/Chemical Dependency History:

. . .

Past treatment for substance use includes .

. .

Past Medical History:

Allergies:
Current medications:

Primary care:
Last physical:


Past Family Psychiatric History:
. .

Past Family Medical/Physical History:
.

Past Family Chemical Dependency History:
.

Cultural impact on health and healthcare.

Health beliefs and engagement in cultural specific healing practices (describe the client's physical health sxs/diagnosis and use of traditional rather than western medical practices in treating illness):



SOCIAL HISTORY:

placements, multiple Moves While Growing Up, change in family composition, socio-economic status, lifestyle, exposure to fam conflict/violence, major illness, loss of fam/friends, loss/separation, Change in School. abuse



Did mother use alcohol, cigarettes, drugs? Illness/accidents/stressors during pregnancy, motor skills, speech, sleep, eating, separation, attachment
Important Developmental Incidence:

.

School/Work History:

The client's level of education is . .. The client is . Financially the client . The client's source of income is primarily .

Current Living situation: . .

Sexual Orientation: .

Marital/relationship History: Currently

Evaluation on quality of relationships:

Social Network/Support Systems/Hobbies & Interests: The client identifies as social support network. The client has children. The client's hobbies/interests include.

Strengths/Personal/Community Resources: The client reports personal strengths as:. The client reports other resources include.

Spirituality/Belief systems: .

Cultural Identification:
Race/ethnicity:
Experience of cultural bias:
Immigration/history of status:
Level of acculturation:
Time orientation:  
Social Orientation/class:
Verbal Communication Style/languages:
Locus of Control:

Family Involvement: Is the family involved in the diagnostic assessment and process?
If so, their agreement to referrals and follow-up plan:

LEGAL HISTORY:
arrests, offenses, tickets, warnings, probation, incarceration
.

Problem List:







SCREENING SCORES

WHODAS 12 item: calculator
GAIN-SS:
ASRS calculator
GAD-7 calculator
PHQ-9 calculator

MENTAL STATUS EXAMINATION:
Reliability: Appears to be a historian
Alert and Oriented:
Appearance: .
Attitude toward the interview: .
Eye contact: .
Psychomotor activity: .
Speech: .
Thought process: .
Thought Content: .
Mood:
Affect: .
Perception: .
Suicidal Ideation: .
Homicidal Ideation:
Insight: .
Judgment:
Cognition/Memory: .
Cognition/Memory - abstraction:



MEDICAL NECESSITY:

Is the client's impairment in functional capacity the result of a mental/emotional disturbance?
Does the client's mental/emotional disturbance significantly impair their functional capacity within an important area of life functioning?
Does the client's mental/emotional disturbance create for the probability of significant deterioration in an important area of life functioning?
Does the client's mental/emotional disturbance create for the probability that they will not progress developmentally as individually appropriate?
Is the client's mental/emotional disturbance a condition which specialty mental health services could correct or ameliorate?
Given the nature of the functional impairment noted above, treatment services will significantly reduce and/or prevent significant deterioration in functioning, and because of that, the following domain/domains of functioning will be treated:

RISK:

The client is currently assessed to be at risk for self harm or suicide as evidenced by The following action was taken as a result of the client having a suicidal ideation/plan/intent:

The client is currently assessed to be at risk of being a harm to others as evidenced by The following action was taken as a result of the client having a homicidal ideation/plan/intent:


CLINICAL FORMULATION:

The client is currently displaying other which is other.

The client would benefit from other.

Prognosis is considering the client medication/therapy to addresstarget of treatment

Barriers to success include barriers. The client's strengths for success include: strengths..

CLINICAL DIAGNOSIS:
Based upon the client's reported symptoms, the client meets criteria for DSM-5:




FOLLOW UP PLAN:


Provider Name: Emily Iwuc, MPS, LADC
Signatures:Service Performed and documented by: Emily Iwuc, MPS, LADC
Supervising Clinician: Cindy Morey, Psy.D., ABPP, MBA, LP
I have read, discussed and agree with the documentation provided by Emily Iwuc, MPS, LADC.
Cindy Morey, Psy.D, ABPP, MB., LP

Result - Copy and paste this output:

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