Use this form to guide your questions during a client interview and to take cursory notes.

Delete the instructions and examples in each section before adding your client's information. The given examples are provided only for your reference to help you

Client Interview

Identifying Information

Begin by completing the basic demographic information for your client.

Name(s):

Date of birth:

Primary language:

Referred by:

Intake date:

Evaluated by:

Description of Client(s)

Briefly describe what you observe about the client's physical status, such as age, gender, ethnicity, appearance, behaviors, and any impressions that stand out to you.

Example: Client is a single Hispanic female in her mid-thirties. She is dressed appropriately for the weather, is well groomed, and appears to be her stated age. She appears slightly anxious as evidenced by her restless fidgeting.

Presenting Problem

Briefly describe why the client is seeking counseling.

It is appropriate to start the session with a question like, "What is the reason for your visit today?" or "What brings you in today?" Summarize the client's response in a few sentences.

Example: Client reports seeking counseling because she is sad, lonely, unmotivated, and feels tired most of the time. She states that this has been getting worse, and she doesn't want to get out of bed in the morning. Her symptoms began about 3 months ago after she broke up with her boyfriend. She recently has called out of work a few days because she didn't have the energy or motivation to go to work.

History of Problem

Describe the symptoms, experiences and background of the problem, previous occurrences, and interventions in a brief paragraph.

Get the client's full story. Be as conversational as possible and listen carefully to what your client is saying. Your goal is to build a friendly relationship, have the client feel comfortable with you, keep the focus on the client and their story, and gather informationnot to sound like this is an interrogation. A release of information to obtain discharge notes from other providers may be appropriate.

Consider using questions or statements that prompt the client to provide details about important topics:

How long this has been a problem?

When did you first notice this problem?

Tell me more about your problem.

How long has this issue been a concern to you?

Have others been concerned or noticed the symptoms?

How often does this problem occur?

How often have the symptoms occurred in the past?

I'd like to hear more about how often this happens.

Have interventions worked?

Have you had counseling for this issue before? If so, what was the outcome of your counseling?

Could you walk me through all the things that you have done in the past, including any previous counseling?

What differences have you had in physical health or emotional mood?

Summarize the client's responses.

Example: Client has a history of these types of symptoms when things in her life change suddenly. She reports she has had feelings of sadness and loneliness often over the past several years, even when she was with her boyfriend. She has times of crying spells, low energy, and lack of interest in activities and in socializing after changing jobs, after moving to a new city, and after her best friend got married and moved away. Client reports that she has never gone to counseling for it in the past, and it usually went away after a month or so. She would sometimes talk to her mom about it, or she has tried reading some self-help books on improving her happiness. This time is different because she needs to keep her job and she can't keep calling out sick.

Social History

Describe the client's social support system in a few sentences, including the following:

where the client lives and with whom

quality of relationships with family and friends

support received from others

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about where you live and with whom.

What are your relationships like?

Who do you get along with well, and who are you not close with?

Summarize the client's responses.

Example: Client recently moved into her own condo after breaking up with her boyfriend of 6 years. They had shared a residence and 2 dogs. Client has 2 close girlfriends whom she has been friends with since grade school, and she can tell her 2 friends anything. Client's mother lives a few miles away and they have a close relationship, although client feels that she can't burden her mother with relationship problems.

Copyright 2021 by University of Phoenix. All rights reserved.

Copyright 2021 by University of Phoenix. All rights reserved.

Biopsychosocial Assessment

Page 3 of 16

Family History

Describe the client's family of origin and relationships with family in the past and present in a few sentences.

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about your family of origin. Who did you live with growing up?

What were the relationships like in your family?

What are your family relationships like now?

Summarize the client's responses.

Example: Client states that she grew up with her dad, mom, and older sister. She describes her family as "an all-American family" with her dad working and bringing home most of the income and her mom having a part-time job for additional "fun money." She recalls her mom and dad having a happy marriage, and she felt that her years growing up were happy. She denies any domestic violence or abuse in the home. Her sister is 3 years older, and she describes her as "bossy." She says that they basically got along fine but her sister always wanted to be the "boss of her" and "tell her what to do." She still has regular contact with her sister, brother-in-law, niece, and nephew, but they don't get together very often due to geographical distance.

School History

Briefly describe the client's educational background and any relevant school history or experiences, including the following:

where the client went to school

years of education completed

positive or negative school experiences

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

How was your school experience growing up?

Did you have friends in school?

Did you go on for post-high school education? If so, what was that experience like?

Summarize the client's responses.

Example: Client describes her experiences in grade school and high school positively, stating that she remembers enjoying learning and her friend group. She attended the state university and obtained a bachelor's degree in marketing. She thought that college would be more fun than it was based on the stories she had been told. She found the rigor difficult and was glad she graduated.

Work History

Describe the client's relevant work history and experiences in a few sentences, including the following:

current employment situation

time spent in the career/profession

positive or negative experiences of work

any sporadic work history or frequent job changes

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about your job. Do you enjoy what you do?

How long have you been in this position?

What types of jobs have you had previously?

Summarize the client's responses.

Example: Client works as an advertising manager at a small firm. She has been there for about 5 years and finds the work unsatisfying. She keeps her position because it pays her bills, and she doesn't have the energy to find something else. Client reports having a few jobs prior in customer service that she didn't enjoy much, either. She states that she has never enjoyed working but always kept a job.

Spiritual

Briefly describe the client's stated spiritual beliefs.

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Clients may choose not to talk about their beliefs or to avoid this topic. Remember that spirituality and religion are not necessarily the same thing. Clients may ask, "Are you asking my religion?" You are not. You are asking for their views of what they believe is greater than themselves, what connects them to the larger universe, or what brings them a sense of peace and purpose.

Consider using questions or statements that prompt the client to provide details about their history:

Do you have a spiritual belief? (You can expect at this point that the client may ask for clarification as to what you are asking. Clarify that having personal spiritual beliefs are not the same as belonging to a church or a religion.)

Summarize the client's responses.

Example: Client states that she does not belong to an organized religion and doesn't attend church but does believe that there is a higher power. In times of stress, she meditates or prays.

Legal

Indicate whether the client has current or previous legal issues. If current, what is the status? Is the client on probation, etc.?

If there are no legal issues, simply state "N/A" to indicate that they are not applicable here.

Trauma History/Abuse

Describe any past or current traumatic events or abusive situations that the client may have experienced. Indicate whether this is ongoing and if the client has received counseling in the past for it.

Keep in mind that the client may not want to disclose their history of trauma or talk about their abuse in depth, especially in the first session. Be sensitive to a client's hesitation to discuss it and remain aware of their discomfort around these topics and questions. Allow them time to respond or respect their silence and the choice to not respond at this time.

Remember to keep the conversation compassionate and flowingdo not overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Have you experienced any type of traumatic events?

Have you been a victim of abuse?

Summarize the client's responses.

Example: Client denies any abuse in her family and does not feel that she has experienced any trauma. Client hesitates when recalling an incident at college, stating, "It was kind of traumatic, I guess." Client does not want to disclose the details of the event at this time.

Suicidal/Homicidal

Indicate if the client has had any suicidal or homicidal thoughts, plans, or attempts. Note if these are in the past or present and if they are passive or active. If client currently has suicidal or homicidal thoughts, complete a full suicide risk assessment. If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

Be sensitive and aware of a client's hesitation to discuss. Risk assessment is necessary if there are any indicators of suicide or homicide. Be direct when asking questions about these topics.

Consider using questions or statements that prompt the client to provide their thoughts:

Have you thought about suicide (or homicide)? (If client says anything other than "no," continue with direct questions or prompts.)

Tell me what you were thinking about.

Do you have a plan?

When is the last time you had this thought?

Summarize the client's responses.

Example: Client denies suicidal or homicidal thoughts.

Example: Client has been having some passive suicidal thoughts. She has not had this in the past. The last time she thought about this was a week ago. She has no plan, no means, and today has no intent.

Example: Client has thought about suicide. Full assessment completed. Client is at moderate risk.

Health and Wellness History

Discuss client's past and present substance use, sleep habits, and exercise and eating habits. Ask direct questions to gather this self-explanatory information.

Substance Use

Includes alcohol, drugs, tobacco, and caffeine intake

Note frequency of use, amount, and duration

Sleep Habits

Exercise Habits

Eating Habits and Appetite

Include any recent weight loss or weight gain.

Mental Status

Assess your client's mental status by discussing what you observe about the client in your session.

Activity

Describe the client's behaviors, especially the client's physical movements.

What did you notice about the client's movements?

Summarize the client's responses.

Example: Client appeared restless and fidgety during the session. She played with her purse strings, engaged in hand wringing, and swung her feet during most of the session.

Mood and Affect

Describe the client's mood and affect (visible expression of feelings and emotions).

What was the client's overall mood?

How did the client show that mood non-verbally (the affect)?

Were these congruent? (Did the client's affect align with the stated mood?)

Summarize the client's responses.

Example: Client said that she was sad and depressed. Her affect during the session was tearful and she often looked down, avoiding eye contact. Her mood and affect were congruent.

Thought Process, Content, and Perception

Describe the client's thought process, content, and perception in how they respond to questions and tell their story.

Listen to how the client responds to questions and presents their story to assess their thought process. Describe their thought process in the telling of their story using terms like logical, illogical, linear, tangential, circumstantial, rational, etc.

Listen for the content of their story and responses to assess their content. Describe their content with words like negative, depressive, obsessive, hopeful, etc.

Listen to their descriptions of reality in their story to assess their perception. Describe whether there are any perceptual disturbances, such as:

Hallucinations - hearing, seeing, or feeling things that are not there

Delusions - thoughts or beliefs that conflict with reality

Illusions - misperceptions, such as hearing the wind and thinking it is someone crying, or seeing a shadow and thinking it is a person

Summarize the client's responses.

Example: Client responded to questions and prompts with a logical and linear thought process. Her story followed a timeline of events and she was easily able to respond to questions directly. Her thought content was negative and depressive. She has difficulty finding anything hopeful in her life. She did not report harmful thoughts. She denied perceptual disturbances.

Cognition, Insight, and Judgment

If completed, indicate any results of a Mini Mental Status Exam (MMSE) in this section. Discuss whether the client appears to understand the symptoms and issues being experienced.

How is the client's insight (ability to recognize the issues and why these issues are occurring)?

How is the client's judgment (ability to make good decisions and behaviors)?

Did you get a sense that the client understands why these things are occurring?

Does the client think about choices and decisions before acting? Has the client been aware of behavioral consequences?

Summarize the client's responses.

Example: Client completed a Mini Mental Status Exam and scored well within the normal range, indicating no cognitive impairments, and estimated average to above average intelligence. It is noted, however, that she had some difficulty in concentration as evidenced by her ability to remember 3 unrelated objects after being distracted and counting backward by 7s. This is consistent with her reports of having a difficult time focusing. Client had good insight and recognized that she is depressed, which she has experienced before under circumstances of change and adjustment. Her judgement is fair, as she does consider her choices and decisions, but also, she is risking her job by choosing to stay in bed for the past few days.

Case Summary

Legal and Ethical

Discuss any potential legal or ethical issues you need to consider as the counselor. This is not about the client having a legal issue.

Consider these factors after you are finished with your intake and are thinking about the case:

Is there a need to break confidentiality due to danger to self or others?

Is there any child or elder abuse or neglect occurring?

What cultural values and considerations should be made with this client?

Are there any dual relationships?

What is your scope of practice?

Use the American Counseling Association (ACA) Code of Ethics as a guide for recognizing and discussing any potential legal and ethical situations.

Summarize the client's responses.

Example: Client stated that she passively thinks about suicide since her breakup, but hasn't had a plan, means, or intent, and has not had a thought in over a week. No risk assessment completed. Client reminded that in the case of danger to self or others, that confidentiality would need to be broken to keep her safe. Client was given numbers for crisis lines and after-hours warm line. Client will be asked at the beginning of each session about suicidal thoughts.

Strengths

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to use resources.

Challenges

Describe aspects of the client's life circumstances that may impede progress or change, such as homelessness, major psychiatric disorder, financial hardship, etc.

Discussion

Summarize the presenting problem and symptoms, along with any pertinent history and social factors that lead to a diagnosis. This section justifies your diagnosis; include any differential diagnoses here.

Consider these factors when writing the discussion:

the symptoms that brought the client in to counseling

the history of the presenting problem

any social, environmental, or medical factors

Summarize the client's responses.

Example: Client presented with sadness, depressed mood, low energy and motivation, loss of appetite, and sleep disturbance. Although she wants to sleep most of the day and does believe that she is sleeping at least 10 hours a day, she does not feel rested. Client has broken up with her long-term boyfriend of 6 years and moved to a new residence. She has lost her boyfriend and the 2 dogs that they owned together. She has a history of feeling lonely, sad, and depressed when there is a major change in her life. She is experiencing more symptoms than she has in the past, primarily evidenced by not going to work, isolating from her best friends, and not eating. These

symptoms have been getting worse over the past 3 months. Adjustment disorder is considered due to the recent changes in her life within the past 3 months. Her symptoms are not out of proportion to the stressor; therefore, ruling out adjustment disorder. Her symptoms meet the criteria for major depressive disorder as evidenced by her sadness, diminished interest in activities, loss of appetite, hypersomnia, and diminished ability to concentrate. Her symptoms are moderate, as evidenced by the interference in her occupational and social functioning. She has had symptoms like these in the past, therefore this is recurrent.

Diagnosis

Using the information gathered thus far, make a diagnosis using the DSM-5. Include the diagnostic title and code as well as any specifiers.

Example: 296.32 - Major Depressive Disorder, moderate, recurrent

Assessments to Support Diagnosis

Identify any assessments that have been used or that you might use to support a diagnosis or rule out a differential diagnosis.

Practice within your scope as a counselor with a master's degree. Remember that you are limited in which assessments you can legally use; you can use the ones in the DSM Library, but not the ones that require a doctorate degree and training outside of your scope.

Example: PHQ-9 and Beck Depression Inventory

Case Conceptualization

Explain the issues, symptoms, and diagnosis of the case through the lens of a theoretical perspective.

Consider these factors when writing the case conceptualization:

the biopsychosocial aspects of the case the theory applied in this case: cognitive behavioral therapy (CBT), humanistic, Adlerian, psychodynamic, or behavioral

how the concepts of the theory explain the client's symptoms and issues

Summarize the client's responses.

Example: The client presented with major depressive disorder symptoms following a triggering event of ending the relationship with her long-time boyfriend and moving to a new residence. Client is lonely and sad but isolating from her friends and not disclosing her depth of sadness to her mom. Client typically enjoys being with her few girlfriends but is now retreating to her bed and avoiding social contact. She has never really enjoyed her work but has been responsible with maintaining her job until recently, when she has called out several days just to stay in bed and sleep all day. This is unlike the client who has been responsible and self-sufficient in the past. Client needs increased social support to help bolster her sense of self and redirect her toward a healthier lifestyle, as she has had in the past. Healthier behavioral choices, challenging negative self-perceptions, and reconnecting with those who care about her would reduce the intensity of the symptoms she is experiencing.

Support your assessment with appropriate terminology from the DSM-5.

Minimum 150 W-Count treatment plan using the Treatment Plan form for this client based on best practice or evidence-based therapy.

Justify your treatment plan with peer-reviewed research.

Cite the selected case and any other supporting resources used.

Format citations and reference according to APA guidelines.

Identifying Information

Client Name: Connie Kellogg

Age: 36 years old

Ethnicity: Caucasian

Marital Status: Married

Occupation: Homemaker

Children: Three children; currently pregnant with her fourth child

Intake Information

Little information was obtained from a phone call interview with Mrs. Kellogg by the intake worker.She Stated that her psychiatrist in Massachusetts had referred her to Dr. Browning in Southfork, Oklahoma, for prescription monitoring. Dr. Browning has referred her to the South Fork Counseling Center to see a therapist. She requested an appointment with a therapist and said only that she had been hospital-ized recently in Massachusetts before moving with her husband and children to Oklahoma. She stated that it was very important that she begin therapy immediately but did not want to discuss any details of the problems she has been experiencing lately.The intake worker scheduled her for the first avail-able appointment with you later in the week.Initial InterviewConnie Kellogg is an attractive, 36-year-old woman whose warm and effervescent personality is apparent from the first meeting. You notice that Connieis several months pregnant. Connie appears eager to get to your office and asks you how long you've lived in Southfork. You explain to her that you moved to South Fork after completing yourmaster's degree 2 years ago."When did you move to Southfork?" you ask.Connie wriggles in her chair and enthusiastically begins talking about her husband being relocated to Oklahoma to accept a new position with his company, which develops software for computer companies. She states that she's never lived in theMidwest, having grown up in Boston. She moved to another town in Massachusetts when she got married 10 years ago."We've been in Southfork for 3 months, and I Feel like a sh out of water," Connie tells you. "I'vegot most of the responsibility for taking care of my three children and as you can see, I'm about to have another one. Bob, my husband, travels 3 or 4 days a week with his job, so I'm stuck at home with my children most of the time... not that I'm complain-ing. Bob has a good job and he has to travel, but it's a lot of work for me, and I haven't made a lot of friends yet. When I lived in Revere, Massachusetts,I had a lot of neighbors who were young mother like me with kids, and we'd get together and baby-sit for each other and take our children to different activities. It was nice until I got sick.""What happened when you got sick?" you askConnie."Well, I've always been a pretty optimistic, up-beat type person with a lot of energy. Then, sud-denly, I had no energy. I was drained. I was so tiredIcouldn't move and just got completely depressed.I was suicidal and felt hopeless about everything.Ithought here I am with three little children and Ican't get off the couch to take care of them. I felt like a complete failure as a mother, just completely worthless. I didn't want to do anything except sleepand block out the entire world. I wasn't interested in sex with my husband. I didn't care if I lived or died. It just got so bad that the psychiatrist I wasseeing put me in the hospital." Connie slinks down in her chair and sighs deeply.She takes a deep breath and then begins talking again. "Everything just looked so black. I couldn't imagine feeling any worse... and my poor kids.All I could think about was that I would die and they would be motherless. And then I began to feel better. I mean like overnight I felt a whole lot bet-ter. I had plenty of energy, and thoughts and ideas just ew through my head and I was on top of the world again. I told the doctor I was just ne and he should let me go home.""How long had you been in the hospital when you began feeling so much better?" you inquire."About 4 weeks," Connie sighs. "Then I was okayor so I thought.""So initially, you were really depressed when you went into the hospital, and then you began to feel much better. Were you taking any medica-tion?" you ask."Well, that's the really scary part about this problem I have. You see, the feeling of being on top of the world didn't last very long. Pretty soon,I was in the depths of despair again, and the medi-cine I was on wasn't working. So, the doctor saidI really needed to be on Lithium. I didn't want to take anything because by then, I knew I was preg-nant again. But I was so depressed I didn't know what else to do. I'm so worried about the medicine affecting the baby. The doctor has put me on a low dosage until the baby is born. I'm just keeping my fingers crossed that the baby will be okay. Do you think that makes me a bad mother?""It sounds as if the psychiatrist thinks you really need to be taking Lithium right now," you respond."You're trying to take care of yourself.""He told me it was absolutely necessary if I Wanted to stay out of the hospital," Connie replies."I never want to go through that experience again.And I'm not sure it's really helping. I have to go get my blood tested every 2 weeks, and I'm not sureI've got enough of the medication in me to do me any good. I have days when I feel like I can function pretty well, and then there are other days when Ifeel like I'm sliding into a black hole and can't get out of it. It's an awful feeling.

These feelings of depression just started about a year ago? Is that correct?" you inquire."Yes, I never felt down in the dumps and com-pletely hopeless like I have this year. You know, Iremember as a child, my father would have periods of deep depression. He was like Dr. Jekyll andMr. Hyde. Some days he'd be great to be around and he'd play with us and laugh. Other times, he was really scary. He'd sit in a dark room and stare out the window for hours, and if any of us kids did anything that perturbed him, he'd get so angry that he'd take us behind the house and give us all a whipping with his belt. You could never tell what kind of mood he'd be in. I was scared of him my whole childhood. I sure hope I'm not turning into someone like him.""Did your father ever see a doctor about hismoods?" you ask."No, he thinks only crazy people see psychia-trists. I told Bob not to tell my parents I was in the hospital. They would have disowned me. They Are strict, conservative Catholics, and believe me,they wouldn't ever understand. They'd tell me I'd Be okay if I went to confession."It seems to you that Connie identifies with her father's mood swings to some degree, and you decide to get more information about Connie's family of origin at this time. "Tell me what it was like for you growing up in Boston," you say.Connie sits back in her chair and looks out the window. "Well, it was your typical Catholic family growing up in the sixties and seventies, I guess. I Have ve siblingstwo older brothers, an older sister, and two younger sisters. My parents were strict and fairly religious. We went to confession onSaturdays and Mass on Sundays every week with-out fail. My mother cared for us while my father worked. We were a middle-class family, I guess. Wenever had a lot of money, but we weren't starving to death either. My parents sent us all to a Catholic school that cost more than public school but wasn't like a private school. I think I bought into all theCatholic guilt thing and have a real problem with feeling guilty about everything. My father rein-forced that feeling of guilt all the time. He was very distant and authoritarian. We got punished a lot as children, and although I don't think I really thought so at the time, it was pretty harsh and it seemed like I was always in the way when my father got mad, and I got punished more than my sisters and brothers.""How do you feel about that time growing up?"you inquire."I guess I consider it a pretty normal childhood,"Connie suggests. "All the kids in the Catholic School I attended grew up much the same way asI did. I think my mother saved us all from my fa-ther's wrath on many occasions. She had a way of diverting his attention away from us when we were in the line of re.""And what is your relationship like now, with your parents?" you ask."Since I've been in the hospital, I've discoveredI have all this anger toward my father," Conniestates. "I've been scared of him my whole life, andI'm tired of feeling that way and I hate how he made me feel. I've never really had any self-esteem and have always felt like I'm cowering in the corner afraid of my own shadow because of what he did to me.""And your mother? How do you get along with her?" you ask.``We get along well. We always have. I think i have a lot in common and she's had to put up with a lot, too," Connie says with a smile

Do you feel that the way you were raised hassomething to do with the depression you've beenexperiencing, or do you think it's unrelated to yourchildhood experiences?" you ask."I don't really know," Connie states. "It's some-thing I want to gure out. The doctor told me someof this could be a neurochemical problem. Some-times, I feel great and full of energy. In fact, it's hardto slow down. I become really talkative and friendly.It's like everything speeds up. Thoughts run throughmy head really fast, and I can't even sleep when I feelthat good. It's like being high.""How often does that happen?" you ask."It seems to happen about once a month after I'vebeen really depressed," Connie states. "But it doesn'tlast as long as the depressed periods.""Do you ever feel that you place yourself in high-risk or dangerous situations when you have a 'high'feeling?" you query."No, I don't think so," Connie reects. "I havesome pretty fantastic thoughts, but I don't actuallydo anything. I've got to think about my childrenand the one on the way.""Okay, so you feel depressed a lot of the time,and sometimes, about once a month, you feel prettygood and full of energy. How long do you usuallyhave that 'high' feeling?" you ask."It can last from 3 or 4 days up to a week be-fore I begin sliding downward again," says Connie. "I always hope it will last longer, but it never does.""So, it sounds like one of your goals is to learnhow to cope with some of these ups and downsyou've been experiencing?" you ask.Connie says enthusiastically, "Yes, exactly, Ineed some help with the best way of coping withthese moods, especially during this pregnancy.""Would it be all right with you if I talked to thepsychiatrist who is prescribing the medication foryou?" you inquire. "I'll need you to sign a consentform.""Absolutely. I'll give you his phone number,"Connie asserts.

And would you like to make an appointment on a weekly basis?" you ask.Connie nods her head vigorously and says,"I'm so glad I've found someone I can talk to who doesn't look at me as if I'm crazy. I definitely want to come once a week to talk to you.""Okay. We'll schedule an appointment for next week," you reply.Connie leaves your office with a little bounce in her step and talks about going to shop for the new baby as you walk her to the reception area.