CLINICAL INTERVIEW:
"PRESENTING ISSUE(S)"
- [Detail presenting issues.] (use as many bullet points as needed to capture the reason for the visit and any associated stressors in detail) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
HISTORY OF PRESENTING ISSUE(S)
- History of Presenting Issue(s): [Detail the history of the presenting issue(s) and include onset, duration, course, and severity of the symptoms or issues.] (use as many bullet points as needed to capture when the symptoms or issue started, the development and course of symptoms) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
CURRENT FUNCTIONING
- Sleep: [Detail sleep patterns.] (use as many bullet points as needed to capture the sleep pattern and how the issue has affected sleep patterns) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
- Employment/Education: [Detail current employment or educational status.] (use as many bullet points as needed to capture current employment or educational status and how the symptoms or issue has affected current employment or education) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
- Family: [Detail family dynamics and relationships.] (use as many bullet points as needed to capture names, ages of family members and the relationships with each other and the effect of symptoms on the family dynamics and relationships) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
- Social: [Describe social interactions and the client’s support network.] (use as many bullet points as needed to capture the social interactions of the client and the client’s support network) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
- Exercise/Physical Activity: [Detail exercise routines or physical activities] (use as many bullet points as needed to capture all exercise and physical activity and the effect the symptoms have had on the client’s exercise and physical activity) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Eating Regime/Appetite: [Detail the eating habits and appetite] (use as many bullet points as needed to capture all eating habits and appetite and the effect the symptoms have had on the client’s eating habits and appetite) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
- Energy Levels: [Detail energy levels throughout the day and the effect the symptoms have had on energy levels] (use as many bullet points as needed to capture the client’s energy levels and the effect the symptoms or issues have had on the client’s energy levels) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Recreational/Interests: [Mention hobbies or interests and the effect the client’s symptoms have had on their hobbies and interests] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
CURRENT MEDICATIONS
- Current Medications: [List type, frequency, and daily dose in detail] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PSYCHIATRIC HISTORY
- Psychiatric History: [Detail any psychiatric history including hospitalisations, treatment from psychiatrists, psychological treatment, counselling, and past medications – type, frequency and dose] (use as many bullet points as needed to capture the client’s psychiatric history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Other interventions: [Detail any other interventions not mentioned in Psychiatric History] (Use as many bullet points as needed to capture all interventions) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
MEDICAL HISTORY
- Personal and Family Medical History: [Detail personal and family medical history] (Use as many bullet points as needed to capture the client’s medical history and the client’s family medical history) (only include if explicitly mentioned in the contextual notes or clinical note, otherwise leave blank)
DEVELOPMENTAL, SOCIAL AND FAMILY HISTORY
Family:
- Family of Origin [Detail the family of origin] (use as many bullet points as needed to capture the client’s family at birth, including parent’s names, their occupations, the parent's relationship with each other, and other siblings) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Developmental History:
- Developmental History [Detail developmental milestones and any issues] (use as many bullet points as needed to capture developmental history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Educational History
- Educational History: [Detail educational history, including academic achievement, relationship with peers, and any issues] (use as many bullet points as needed to capture educational history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Employment History
- Employment History: [Detail employment history and any issues] (use as many bullet points as needed to capture employment history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Relationship History
- Relationship History: [Detail relationship history and any issues] (use as many bullet points as needed to capture the relationship history) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Forensic/Legal History
- Forensic and Legal History: [Detail any forensic or legal history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
SUBSTANCE USE
- Substance Use: [Detail any current and past substance use] (use as many bullet points as needed to capture current and past substance use including type and frequency) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
RELEVANT CULTURAL/RELIGIOUS/SPIRITUAL ISSUES
- Relevant Cultural/Religious/Spiritual Issues: [Detail any cultural, religious, or spiritual factors that are relevant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
RISK ASSESSMENT
Risk Assessment:
- Suicidal Ideation: [History, attempts, plans] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Homicidal Ideation: [Describe any homicidal ideation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Self-harm: [Detail any history of self-harm] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Violence & Aggression: [Describe any incidents of violence or aggression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Risk-taking/Impulsivity: [Describe any risk-taking behaviors or impulsivity] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
MENTAL STATE EXAM:
- Appearance: [Describe the client's appearance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Behaviour: [Describe the client's behaviour] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Speech: [Detail speech patterns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Mood: [Describe the client's mood] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Affect: [Describe the client's affect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Perception: [Detail any hallucinations or dissociations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Thought Process: [Describe the client's thought process] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Thought Form: [Detail the form of thoughts, including any disorderly thoughts] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Orientation: [Detail orientation to time and place] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Memory: [Describe memory function] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Concentration: [Detail concentration levels] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Attention: [Describe attention span] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Judgement: [Detail judgement capabilities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Insight: [Describe the client's insight into their condition] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
TEST RESULTS
Summary of Findings: [Summarize the findings from any formal psychometric assessments or self-report measures] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
DIAGNOSIS:
- Diagnosis: [List any DSM-5-TR diagnosis and any comorbid conditions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
CLINICAL FORMULATION:
- Presenting Issue: [Summarise the presenting issue] (Use as many bullet points as needed to capture the presenting issue) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Predisposing Factors: [List predisposing factors to the client's condition] (Use as many bullet points as needed to capture the predisposing factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Precipitating Factors: [List precipitating factors that may have triggered the condition] (Use as many bullet points as needed to capture the precipitating factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Perpetuating Factors: [List factors that are perpetuating the condition] (Use as many bullet points as needed to capture the perpetuating factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Protecting Factors: [List factors that protect the client from worsening of the condition] (Use as many bullet points as needed to capture the protective factors) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Case formulation:
[Detail a case formulation as a paragraph] [Client presents with (issue), which appears to be precipitated by (precipitating factors). Factors that seem to have predisposed the client to the (issue) include (predisposing factors). The current issue is maintained by (perpetuating factors). However, the protective and positive factors include (Protective factors)].