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L2 : Intake, MSE & Suicide Assessment (Clinical Interview (Intake)…
L2 : Intake, MSE & Suicide Assessment
Clinical Interview (Intake)
Medical & psychiatric history
Developmental History
Marital & Family r/s
Education History
Employment history
Presenting problem
Substance abuse & legal history
Background info & family structure
History - present problems
Strengths & assessment - support system
Mental Status Exam
Speech
Mood & affect
Orientation
Thought process
Attitude
Attention span
Behaviour
Memory
Appearance
Progress Notes
continuous assessment
legal reasons (protection - counsellors)
keep track client - progress
SOAP
many diff. versions
Suicide Assessment
Determine high / low risk
Sign contract
Break confidentiality
Ideation :vs: Plans
psychiatric referral / hospitalization
what to ask? (rigid & direct)
no harm contract
emergency contacts
protect counsellor legally
determine threat level / risk