A. Complete identifying information of client/member of client/member seeking services

     1. Name and address of service

     2. Make copies of ID cards and insurance cards if apply
     3. Client has a legal  guardian or conservator who makes

         decision on behalf of client/member?

     4. Discuss "do's" and "don'ts of confidentiality (HIPAA)
 
B. Referral Source
    1. Referral source clearly stated
    2. Important facts prompting need for services
    3. Specific referral questions noted

D.  Presenting Problem
   1. Presenting problem stated in terms of psychiatric symptoms
   2. All psychiatric symptoms listed
   3. Symptoms described as specifically as possible

      (frequency,duration, intensity)

E.  History of Presenting Problem
   1. Onset clearly stated
   2. Précipitants or environmental stressors described
   3. Course of disorders specified

F. Other Relevant History
   1. Siblings and birth order reported
   2. Early childhood, middle childhood, & adolescence described
   3. Adult history described: Educational history Work history

       Dating or marital history Substance use history Sexual  

       history Interpersonal relationships with family and friends

       Current social life Legal and criminal history Medical

       problems Religion Leisure activities
  4. Client's psychiatric history
  5. Family psychiatric history
  6. History of physical/sexual abuse, sexual assault, or intimate

      partner violence

G. Mental Status Examination and Client Strengths
    1. Client demographics
    2. Appearance, attire, grooming, hygiene
    3. Eye contact
    4. Behavior during interview
    5. Attitude toward interviewer
    6. Mood and affect
    7. Speech and organization of thoughts
    8. Orientation
    9. Attention, memory, and concentration

    10.  Intelligence
    11. Reliability of information
    12. Judgment and insight
    13. Suicidal and homicidal ideation, plan, and intent
    14. Absence/presence of delusions and hallucinations
    15. Use of alcohol, drugs, and medications

H. DSM-IV Diagnosis
    1. Five axes addressed
    2. Full name for each Axis I and Axis II disorder provided
    3. Official code numbers provided for each diagnosis
    4. Diagnosis supported by symptoms in the presenting

        problem
    5. On Axis III, general medical conditions noted
    6. On Axis IV, psychosocial and environmental problems noted
    7. On Axis V, current functioning noted on Global Assessment

        of Functioning (GAF) Scale
 

Treatment Goals and Objectives

    1. Goal:

    1. Objective

    2. Goal:

    2. Objective: