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Initial Clinical Assessment &

Treatment Plan

Clinician Treatment Tools

Initial Mental Health Counseling

Assessment & Treatment Plan

 

Mental Health Counselors need to utilize a comprehensive outline to perform a complete and thorough assessment of the needs of the clients who enter counseling. Mental Health Counselors also need to detail a plan for treatment of their clients.

 

Initial Assessment Components

1. The "Why now?"

Description of presenting problems with list if specific symptoms/complaints that justify diagnosis and need for treatment and duration of symptoms (estimate if unknown)

2. Clinical Mental Health History

Include prior treatment for psychiatric and substance abuse problems, including hospitalizations, etc.

3. Current psychotropic medications

List with who prescribes and size of prescription for each medication

4. Medical History

Status of current health of client and relevant current or former medical conditions which could relate to the current presenting problems

5. Family History including the following

  • Family Geneogram
  • Family of Origin
  • Family Mental Health and/or Substance Abuse History

6. Social History

  • Schooling
  • Community involvement
  • Racial/Cutlural related issues

7. Vocational History

  • Level of current employment
  • Relevant past employment history
8. Client’s strengths      

9. Client’s liabilities

10. Relevant ACE (Adverse Childhood Experience  

  • Abuse: Emotional, Physical, Sexual
  • Neglect: Emotional Physical
  • Family Dysfunction: Mother Treated Violently; Household: Substance Abuse; Mental Illness; Parental Separation: Incarcerated Household Member

11. Mental Status including the following

  • Appearance 
  • Consciousness
  • Orientation
  • Speech
  • Affect
  • Mood
  • Concentration
  • Activity Level
  • Thoughts
  • Memory
  • Judgment 

12. Clinical Assessment Tool Utilized 

List one or more clinical assessment tools you have utilized to help formulate your diagnosis and treatment plan. For possible clinical assessments tools see: http://coping.us/cliniciantreatmenttools/assessmenttools.html

13. Diagnosis based on DSM-5 Criteria

  • Principal Diagnosis
  • Provisional Diagnosis
  • Other Condition that May Be a Focus of Clinical Attention

14. Treatment Plan  

  • 3 Long Term Goals
  • 3 Behavioral Objectives per Goal
  • 3 Clinical Interventions per Goal e.g. one per each objective
Always Consider using one or more Clinical Assessments of Client's Functions
An overview of assessments is available at:

http://coping.us/cliniciantreatmenttools/assessmenttools.html

Keep the ACE Criteria into Consideration when Doing an Initial Assessment

 
The Center for Disease Control has done studies on the impact of Adverse Childhood Experiences on the health of individuals. The ACE study has found that these adverse experiences are major risk factors leading to mental illness and poor quality of life. These adverse childhood experiences must be related to when doing a initial assessment of clients.
 
Read about the Adverse Childhood Experiences ACE Study at: http://www.cdc.gov/violenceprevention/acestudy/index.html
 
Download Questionnaires on the ACE called the Behavioral Risk Factor Surveillance System Survey (BRFSS) Adverse Childhood Experience (ACE) Module at: http://www.cdc.gov/violenceprevention/acestudy/pdf/brfss_adverse_module.pdf
 
ACE (Adverse Childhood Experiences)

Abuse

1. Emotional Abuse

2. Physical Abuse

3. Sexual Abuse

Neglect

4. Emotional Neglect

5. Physical Neglect

Household Dysfunction

6. Mother was treated violently

7. Household substance abuse

8. Household mental illness

9. Parental separation or divorce

10. Incarcerated household member

 
Watch a video called: "Healing Neen" to hear about how one woman has overcome having all 10 ACE factors in her life. Get the video at: http://www.cmhnetwork.org/media-center/videos-blog-old/healing-neen


Watch a TED Talk by Dr Nadine Burke Harris on How childhood trauma affects health across a lifetime at:


To learn more about Trauma Focused Therapy Cognitive Behavioral Therapy which is mentioned in the ACE materials go to: http://tfcbt.musc.edu/. On this site you are able to take an online course in TFCBT as well.
Document
Initial Clinical Mental Health Assessment & Treatment Plan based on DSM-5 Criteria Updated 2-28-19
Document
ICD-10-CM Codes for ACE Factors to enhance diagnostic process Updated 10-29-15
Document
ICD-10-CM Codes for DSM-5 Diagnostic Classifications updated 10-29-15
Document
ICD-10-CM Codes for Common Medical Conditions Related to Mental Health Disorders Updated 10-29-15

Mental Health Awareness Through Wristbands


An excellent resource to spread the word on Mental Health Awareness is avaiable at: https://www.wristbandexpress.com/content/mental-health-awareness-through-wristbands

This wonderful resource was pointed out to us by: a Girl Scout Troop in Seattle Wasington and we thanks them for their conscientious effort to get word out about Mental Health Awareness.