What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?
Assignment: CURRENT LIVING SITUATION
Living Situation
Dependents/Care for Dependents Employment/Disability/Seeking Disability Income/Source of Income
Insurance Transportation Daily Living Skills
Social/Leisure Activities
Available Social Support
BIRTH AND DEVELOPMENTAL HISTORY
A. PRENATAL/BIRTH/DEVELOPMENT
Pregnancy and Labor Developmental Milestone(s)
B. EARLY CHILDHOOD
Family of Origin—Parents/Siblings/Extended Family, as Relevant
Geographic/Cultural/Spiritual Factors/as Relevant
Abuse/Trauma History
Physical/Emotional/Sexual Abuse History
SCHOOL AND SOCIAL RELATIONSHIPS
This section should include information about social supports and the nature of those relationships; include current friendships, school/peer group experience, and military history, if applicable.
A. SOCIAL DEVELOPMENT
Cultural/Peer Group/Environment School
Adolescence
B. EDUCATIONAL HISTORY
Public or Private School(s) Where Attended
Performance
Educational Level
Extracurricular Activities
C. MILITARY HISTORY What Branch
Duty Assignment (when/where) Rank/Discharge
FAMILY MEMBERS AND RELATIONSHIPS
A. SIGNIFICANT FAMILY RELATIONSHIPS
Family member and relationship
Relationship dynamics
B. INTERPERSONAL/MARITAL HISTORY
Age of Involvement in Relationships
Sexual Orientation
Length of Relationships
Relationship Patterns/Problems
Partner’s Age/Occupation
HEALTH AND MEDICAL ISSUES
A. MEDICAL HISTORY/HEALTH STATUS
History of Traumatic Injuries/Illnesses/Chronic Health Problems
Describe Current Illness
Is Client in Good General Health?
Is Client Allergic to Any Medications? Who Is Client’s Primary Care Physician?
Is the Client Being Treated by Any Other Physician(s)?
What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?
Describe Client’s Health Habits: Appetite, Sleep, Exercise, Nicotine, Alcohol, Illicit Drugs, and Vitamins/Herbal Supplements?
Sexual Functioning: Preference/Problems
Pregnancy/Birth Control
Risk Behaviors for STDs
B. MENTAL STATUS
Attitude/Appearance/Behavior Affect/Mood/Psychomotor Activity
Orientation/Memory/Cognition Thought Process/Content Speech
Insight/Judgment Homicidal/Suicidal Ideation Hallucination(s)/Delusion(s)
C. HISTORY OF PSYCHIATRIC ILLNESS AND PREVIOUS TREATMENT
Previous Diagnoses/Medications/Inpatient and Outpatient Treatment History of Suicidal Ideation/Suicide Attempts/Self-Mutilation/Homicidal Ideation/Aggression
E. SUBSTANCE ABUSE HISTORY
Type/Onset/Duration/Amount Frequency/Pattern of Use Involvement in Treatment
SPIRITUAL DEVELOPMENT
Religion/spirituality
SOCIAL, COMMUNITY, AND RECREATIONAL ACTIVITIES
CLIENT STRENGTHS, CAPACITIES AND RESOURCES
Cultural/ethnic factors
Personal strengths
Family/social resources
OTHER SIGNIFICANT FACTORS
