Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Faculty Information
Faculty Name: David Moore, Ph.D. CDP
Contact Information: ddmoore@argosy.edu; 206.393.3548
Short Faculty Bio: Dr. Moore is an Associate Professor of the Counseling Psychology Department at Argosy
University/Seattle. He was awarded both his M.Ed and Ph.D. in Counseling Psychology from the University of
Washington/Seattle. After initiating along with teaching graduate-level behavioral science courses in the
College of Education at the Universities of Washington and Puget Sound, he served as a research faculty
member at Johns Hopkins School of Public Health’s Department of Mental Health.
Your classmates will receive all the documents on the right hand side of the graphic. The Progress Notes
should be a summary of three hypothetical sessions you have with the client. That is attached to the
Individualized Treatment Plan [called the “Case Formulation”]. In addition it is expected that you will
provide a two page paper describing the unique issue in the case; along with 1-2 journal articles that
amplify on your discussion.
Dr. Moore will also receive your two Information Forms and a Client Termination Form that describes
the ending and referrals for the client.
The goal of this comprehensive approach is to have each student complete an in-depth evaluation that
would have enough information that it could be used as a teaching case.
Page 1
Client Information Form 1
Today’s date:
Note: If you have been a patient here before, please fill in only the information that has changed.
A. Identification
Your name: Date of birth: Age:
Nicknames or aliases: Social Security #:
Home street address: Apt.:
City: State: Zip:
Home/evening phone: e-mail:
Calls or e-mail will be discreet, but please indicate any restrictions:
May I have your permission to thank this person for the referral? ❑ Yes ❑ No
How did this person explain how I might be of help to you?
C. Your medical care: From whom or where do you get your medical care?
Clinic/doctor’s name: Phone:
Address:
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can
be fully informed and we can coordinate your treatment? ❑ Yes ❑ No
Work phone: Calls will be discreet, but please indicate any restrictions:
(cont.)
FORM 23. Client demographic information form (p. 1 of 3). From The Paper Office. Copyright 2003 by Edward L.
Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Client Information Form 1 (p. 2 of 3)
G. Family-of-origin history
Current age (or Illnesses (or cause of
Relative Name age at death) death, if deceased) Education Occupation
Father
Mother
Stepparents
Grandparents
Uncles/aunts
Brothers
Sisters
(cont.)
Client Information Form 1 (p. 3 of 3)
Second
Third
Current
I. Marital/relationship history
Second
Third
J. Children (Indicate which are from a previous marriage or relationship with the letter P in the last column)
Current
Name age Sex School Grade Adjustment problems? P?
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Client Information Form 2
Note: If you were a patient here before, please fill in only the information that has changed.
A. Identification
Name: Date:
B. Chief concern
Please describe the main difficulty that has brought you to see me:
C. Treatment
1. Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before?
❑ No ❑ Yes If yes, please indicate:
When? From whom? For what? With what results?
2. Have you ever taken medications for psychiatric or emotional problems? ❑ No ❑ Yes If yes,please indicate:
When? From whom? Which medications? For what? With what results?
(cont.)
FORM 24. Client clinical information form (p. 1 of 4). From The Paper Office. Copyright 2003 by Edward L. Zuckerman.
Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Client Information Form 2 (p. 2 of 4)
2. Your relationship with each parent and with other adults present:
3. Your parents’ physical health problems,drug or alocohol use,and mental or emotional difficulties:
4. Your relationship with your brothers and sisters,in the past and present:
E. Abuse history: ❑ I was not abused in any way. ❑ I was abused. If you were abused, please indicate the fol-
lowing. For kind of abuse, use these letters: P = Physical, such as beatings. S = Sexual, such as touching/molesting, fon-
dling, or intercourse. N = Neglect, such as failure to feed, shelter, or protect. E = Emotional, such as humiliation, etc.
Your Kind of Consequences
age abuse By whom? Effects on you? Whom did you tell? of telling?
F. Present relationships
1. How do you get along with your present spouse or partner?
(cont.)
Client Information Form 2 (p. 3 of 4)
G. Chemical use
1. Have you ever felt the need to cut down on your drinking? ❑ No ❑ Yes
2. Have you ever felt annoyed by criticism of your drinking? ❑ No ❑ Yes
3. Have you ever felt guilty about your drinking? ❑ No ❑ Yes
4. Have you ever taken a morning “eye-opener”? ❑ No ❑ Yes
5. How much beer,wine,or hard liquor do you consume each week,on the average?
6. Are there times when you drink to unconsciousness,or run out of money as a result of drinking?
7. How much tobacco do you smoke or chew each week?
8. Have you ever used inhalants (“huffing”),such as glue,gasoline,or paint thinner? ❑ No ❑ Yes If yes,which and
when?
9. Which drugs (not medications prescribed for you) have you used in the last 10 years?
Please provide details about your use of these drugs or other chemicals,such as amounts,how often you used them,
their effects,and so forth:
H. Legal history
1. Are you presently suing anyone or thinking of suing anyone? ❑ No ❑ Yes If yes, please explain:
2. Is your reason for coming to see me related to an accident or injury? ❑ No ❑ Yes If yes,please explain:
3. Are you required by a court, the police, or a probation/parole officer to have this appointment? ❑ No ❑ Yes
If yes,please explain:
(cont.)
Client Information Form 2 (p. 4 of 4)
4. List all the contacts with the police,courts,and jails/prisons you have had.Include all open charges and pending ones.
Under “Jurisdiction,” write in a letter: F = federal, S = state, Co = county, Ci = city. Under “Sentence,” write in the
time and the type of sentence you served or have to serve (AR = accelerated or alternate resolution,CS = commu-
nity service, F = fine, I = incarceration, Pr = probation, Po = parole, O = other, R = restitution).
I. Other
Is there anything else that is important for me as your therapist to know about, and that you have not written about on
any of these forms? If yes, please tell me about it here or on another sheet of paper:
J. Follow-up by clinician
Based on the responses above and on ❑ interview data ❑ records I reviewed ❑ other information
I have requested the client to complete and/or I have completed the following forms:
❑ Chemical use survey
❑ Suicide risk assessment summary and recommendations
❑ Mental status evaluation report
❑ Other:
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Individualized Behavioral/Mental Health Treatment Plan
This is for ❑ Preauthorization for initial certification ❑ Concurrent review for reauthorization of care
A. Identification
Client’s name: Soc.Sec.#: ID #:
Membership #: Date of birth: Sex:
Group name/#: Certificate #:
Name of subscriber/member,and address (if other than client):
Release-of-records form(s) signed: ❑ Yes ❑ Not yet
B. Case formulation/overview
b.
c.
*Code impairment as follows (per GAF Scale): 80–90 = mild, 60–70 = moderate, 40–50 = severe, 30 or less = very severe.
(cont.)
FORM 38. Individualized treatment plan for managed care organizations (p. 1 of 6). From The Paper Office.
Copyright 2003 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only
(see copyright page for details).
Individualized Behavioral/Mental Health Treatment Plan (p. 2 of 6)
C. Present level of functioning/limitations/impairment (describe specific impairments at left, and rate degree of
functional impairment at right with GAF number [100 = none, 70 = little, 30 = significant, 10 = incapacitated] or use
descriptors):
GAF
Area of functioning rating
1. School/work functioning:
2. Intimate relationship/marriage:
3. Family/children:
4. Social relationships:
5. Psychological/personal functioning:
6. Other areas:
D. Assessment conclusions
1. Assessment of currently known risk factors:
a. Suicide: ❑ Not assessed ❑ No known behaviors ❑ Ideation only ❑ Plan
❑ Intent without means ❑ Intent with means
b. Homicide: ❑ Not assessed ❑ No known behaviors ❑ Ideation only ❑ Plan
❑ Intent without means ❑ Intent with means
c. Impulse control: ❑ Not assessed ❑ Sufficient control ❑ Moderate ❑ Minimal ❑ Inconsistent
d. Compliance with treatments: ❑ Not assessed ❑ Full compliance ❑ Minimal noncompliance
❑ Moderate noncompliance ❑ Variable ❑ Little or no compliance
e. Substance abuse/dependence: ❑ Not assessed ❑ None/normal use ❑ Overuse ❑ Abuse
❑ Dependence ❑ Unstable remission of abuse
f. Current physical or sexual abuse: ❑ Not assessed ❑ No ❑ Yes Legally reportable? ❑ Yes ❑ No
g. Current child/elder neglect: ❑ Not assessed ❑ No ❑ Yes Legally reportable? ❑ Yes ❑ No
If yes, client is ❑ Victim ❑ Perpetrator ❑ Both ❑ Neither, but abuse exists in family
h. If risk exists: Client ❑ can ❑ cannot meaningfully agree to a contract not to harm ❑ self ❑ others ❑ both
I. History that may affect current level of risk or impairment of functioning:
j. Other concerns:
(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 3 of 6)
Axis I
Axis II
Axis III—Significant and relevant medical conditions, including allergies and drug sensitivities:
Condition Treatment/medication (regimen) Provider Status
Axis IV—Psychosocial and environmental problems in last year; overall severity rating:
❑ Problems with primary support group ❑ Problems related to the social environment
❑ Educational problems ❑ Occupational problems
❑ Housing problems ❑ Economic problems
❑ Problems with access to health care services
❑ Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems (specify):
Axis V—Global Assessment of Functioning (GAF) rating: Currently: Highest in past year:
(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 4 of 6)
E. Treatment plan (if additional problems are to be addressed, use copies of this page):
Significant improvement is to be expected, with treatment as specified, for:
Problem 1:
■ Behaviors to be changed:
■ Interventions (who does what, how often, with what resources; modality, frequency, duration):
Problem 2:
■ Behaviors to be changed:
■ Interventions (who does what, how often, with what resources; modality, frequency, duration):
Problem 3:
■ Behaviors to be changed:
■ Interventions (who does what, how often, with what resources; modality, frequency, duration):
(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 5 of 6)
5. Further assessments, based on current clinical evaluation, are needed to answer these concerns or rule out
these possible coexisting conditions:
❑ Psychological presentation/symptoms of medical condition
Likely possible sources: ❑ Thyroid ❑ Diabetes ❑ Alcohol/drug misuse ❑ Circulatory problem
❑ Neurological problem ❑ Poor nutrition ❑ Medication interactions ❑ Toxin exposure
❑ Other:
❑ Sexual dysfunctions ❑ Factitious disorders ❑ Substance abuse/dependence
❑ Psychophysiological disorders ❑ Learning disabilities
❑ Genetic disorders/counseling ❑ Other:
6. Documents to be obtained (have requests for records completed and signed,photocopied,and placed in client’s
file so that receipt can be assured):
Type of record Source Date of first request
❑ Medical/physician/hospital
❑ School
❑ Agency
❑ Other:
(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 6 of 6)
G. Administrative
1. Case manager’s additional suggestions for treatments and resources:
Date Name Suggestions
. 2. Services:
Sessions Date of Start of Number of ses- Date of Date of
requested* request sessions sions authorized authorization next review
*Code sessions with a number (number of sessions) and letter: C = Collateral contacts, E = Evaluation, F = Family therapy,
G = Group therapy, I = Individual therapy.
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
This report reflects the patient’s condition at the time of consultation or evaluation. It does not necessarily reflect the patient’s di-
agnosis or condition at any subsequent time.
Progress Note
If a checkbox (❑) is inappropriate or insufficient, enter a letter and write additional comments on a separate page.
C. Treatments/interventions/techniques
❑ Insights
❑ Behavioral
❑ Cognitive
❑ Homework given
❑ Family
❑ Relationship
❑ Problem solving
❑ Support
(cont.)
FORM 41. Structured progress note form (p. 1 of 2). From The Paper Office. Copyright 2003 by Edward L. Zuckerman.
Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Progress Note (p. 2 of 2)
D. Assessments
1. Symptoms
Change since last evaluation (enter a check mark)
Current
severity No Less Much im- Resolved/ More Much
Symptom/concern/complaint rating* change severe proved absent severe worse
*Rate from 0 to 10 as follows: 0 = not a problem/resolved; 5 = distressing/limiting; 10 = very severe distress, disruption, harm/risk.
G. Follow-ups
❑ Next appointment is scheduled for next ❑ week ❑ month ❑ 2 months ❑ 3 months ❑ as needed.
❑ Referral/consultation to: For:
❑ Call/write to: For:
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Termination Summary
Client: Date:
Signature(s) of therapist(s) :
C. Treatment sessions
Referred on date: Date of first contact: Date of last session:
Number of sessions: Scheduled: Attended: Cancelled: Did not show:
E. Treatment goals and outcomes (code outcomes as follows: N = no change, S = some or slight [about 25% to
35%], M = moderate [about 50%], V = very good [about 75% to 100%], E = exceeded expectation)
Goal Outcome
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
FORM 44. Termination summary form. From The Paper Office. Copyright 2003 by Edward L. Zuckerman. Permission to
photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).