For clinicians to get a sense of who their clients are and what has brought them to treatment, here are some initial questions and two assessments that are done early on in the therapeutic relationship. Given the newness of the therapeutic relationship, clinicians are trying to create rapport while embarking on this detailed level of questioning.  As such, it is essential that the clinician communicate, verbally and non-verbally, that the ultimate goal is to enable the clinician to help the client achieve his/her own goals, primarily symptom reduction. For  some clients, this may be the first time they have ever spoken about this aloud. Imagine the challenge this represents. The key message: the answers will be received with sensitivity and respect and, most importantly, without any judgment.

1. Primary reason for visit?
2. How is this impacting daily life? (might include scaling the severity, ex. 1-10)
3. How long have the symptoms been present? (including any trigger event)
4. Any previous experience with mental health professionals? (this can give insight into client’s perspective on therapy)

Biopsychosocial Assessment

• Bio: physical health (ex. illness, prescription medication, illegal drugs, alcohol, surgery, injury, sleep & eating patterns)
• Psycho: emotional health (ex. history of mental illness; any type of abuse – physical, emotional, sexual – of self or others***; addictions)
• Social: environmental influences, experiences, stressors (includes social, economic, professional, academic, residential, legal)
• Essentially, an audit of each domain – past and present, including family history, particularly in the emotional health segment (due to potential genetic link to client’s current presentation)
• Assertion that the interplay of each area impacts current mental health presentation

Mental Status Exam 

• Gathered through inquiry and observation
• Physical presentation (hygiene, speech, movement, eye contact)
• Orientation: people, place, time
• Thoughts:  content & process (ex. grounded, able to sequence vs signs of delusions)
• Perceptions (ex intact vs auditory or visual hallucinations)
• Mood (ex sad, depressed, angry)
• Affect (visible signs of mood – may or may not be congruent with stated mood)
• Risk to self *** (ex suicidality)
• Risk to others *** (ex homicidality, grave bodily harm)

*** it is critical to evaluate these elements immediately (recall caveats to confidentiality); the clinician is asking about and looking for signs, including stated harm to self or others, plan (what & how it would be done) and means (ability to carry out plan)

The intent behind this data gathering is to enable the clinician to formulate a diagnosis (per the DSM) and, ultimately, a treatment plan. For clinicians billing insurance and/or clients submitting invoices, this due diligence is necessary to substantiate medical necessity, the criteria for reimbursement.

I have included an example for your review. Interpreters can use these as a guide for terminology, particularly for the biopsychosocial assessment, as these are questions that will likely be asked of the LEP.

Click to access mse.pdf

Click to access Assessment-Form_Adult_072412_saveable.pdf