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Explained Limits of Confidentiality
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Initials by therapist
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Age
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Sex/Orientation
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Ethnicity
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Language
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Currently lives with
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Court Ordered Custody
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Comments
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Current Presenting Problem / Symptoms
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Nature & History, including precipitating event(s), job/school/living situation, etc.
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Mental Status Exam
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Appearance
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Orientation
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Speech
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Thought Process
• • •
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Thought Content
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Others please specify
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Perceptual Process
• • •
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Others please specify
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Insight
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Judgement
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Mood
• • •
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Affect
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Memory
• • •
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Medical history - Past or current history and/or treatment of
• • •
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Child/Adolescent History
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Developmental Issues/History
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Did patient meet developmental milestones?
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Thought Disorder Symptoms
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Psychiatric History
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Outpatient/Inpatient services
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Current Medication
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Comments
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Medication compliant
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Comments
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Name of Psychiatrist/Physician
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Consent for Release of Information to communicate with MSMHS
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Past Psychiatric Medication
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Comments
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Psychosocial History
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Education History
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Employment History
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Social / Cultural Support
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Spirituality
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Financial stressors
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Legal Issues
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Family History
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Family Background
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Relationship History of Parents
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Family Trauma (loss, moves, separation)
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Family History of Psychiatric Services
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Family History of Substance Abuse
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Risk Assessments - Suicide
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Suicide - History
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If yes please explain
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Suicide - Ideations
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If yes please explain
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Suicide - Plan
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If yes please explain
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Suicide - Means
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If yes please explain
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Suicide - Safety plan
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If yes please explain
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Homicide
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Homicide - History
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If yes please explain
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Homicide - Ideations
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If yes please explain
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Homicide - Plan
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If yes please explain
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Homicide - Means
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If yes please explain
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Homicide - Safety plan
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If yes please explain
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Access to Weapons
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If yes please explain
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Substance Abuse
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Substance Abuse - Current history
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If yes please explain
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Substance Abuse - Past history
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If yes please explain
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History of Abuse
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History of abuse - Neglect
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If yes please explain
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History of abuse - Physical
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If yes please explain
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History of abuse - Psychological
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If yes please explain
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History of abuse - Reported in Past
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If yes please explain
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Case Summary
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Diagnosis
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Plan/Interventions
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