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CoachMorningGerbil13
After reviewing the sample clinical interview and Jones (2010)…
After reviewing the sample clinical interview and Jones (2010) article, describe which sections you feel are most critical to explore and why.
Clinical assessment is an important part, and one should pay close attention to important details. However, how can one acquire these important details? Your statement, “demographic and identifying information, presenting problem/chief complaint history of presenting problem, family history, relationship history, developmental history, medical history, medical history, substance use, and previous counseling,” illustrate what one can do to get such information. This quote from your work details what an effective and fruitful clinical assessment should entail.
Which do you feel are unnecessary? Why?
I agree with what you feel is unnecessary. However, I am afraid I have to disagree with you on the issue of mental status examination. I believe it is essential to explore the patient’s mental status’s role in their overall health or the specific issue being addressed.
Compare and contrast the two tests selected in terms of reliability and validity.
Your statement, “a test can be legitimate without being trustworthy, and vice versa,” is interesting. I believe the reliability of a test is a necessary but not sufficient condition for its validity. While a valid test will invariably exhibit reliability, the converse is not necessarily true, as a test may demonstrate reliability without validity. The reason for this is that a test has the potential to yield consistent outcomes on multiple occasions. However, it may not necessarily assess the construct it intended to evaluate.
Do you feel confident in the results of each test selected? Why or why not
I do agree with you on the results of self-esteem. Every person knows themselves better; no one can dispute the accuracy or findings of that test. Only the individual who took the tests knows their self-esteem level.
When considering the limitations of clinical interviews presented in your text, how do clinical tests fill the gaps in the diagnostic process?
I also believe clinical interviews are a crucial component of the healthcare process. They enable providers to gather pertinent information to develop a comprehensive plan, establish treatment goals, and determine appropriate interventions. The uniformity of medical care remains consistent across various healthcare providers, regardless of their specific type. A comprehensive evaluation of an individual’s physical and emotional state is equivalent to an appraisal of their subjective experience. Clinical testing involves the collection of comprehensive data regarding the psychological condition of a patient (Comer & Comer, 2019).
References
Comer, R. J., & Comer, J. S. (2019). Fundamentals of Abnormal Psychology
(9th Edition). Macmillan Higher education.
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Resources.
Comer, R. J., & Comer, J. S. (2019). Fundamentals of abnormal psychology (9th ed.). Worth.
Chapter 3, “Clinical Assessment, Diagnosis, and Treatment”
Jones, K. D., (2010). The unstructured clinical interviewLinks to an external site.. Journal of Counseling & Development, 88, 220-226.
Copy of unstructured interview.
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 1 of 6
The following Unstructured Clinical Interview is just a sample, and clinical interviews will vary by
clinician and purpose. Most clinical interviews will gather the following data in varying order (Jones,
2010):
A. Demographic and identifying information
B. Presenting problem or chief complaint
C. History of presenting problem
D. Family history
E. Relationship history
F. Developmental history
G. Educational history
H. Work history
I. Medical history
J. Substance use
K. Legal history
L. Previous counseling
M. Mental status examination (MSE)
Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling & Development, 88(2),
220-226.
Client Name: __________________________________________ DOB: __________________ Age ____________
Sex: M / F Address: ___________________________________________ Preferred Phone: __________________
Are you a college student? Yes / No / FT / PT Are you employed? Yes / No / FT / PT
Name of your employer and/or school and occupation: ___________________________________________________
Significant relationship status (check one): ?single ?engaged ?married ?separated ?divorced ?committed
relationship ?other _____________________
If married, spouse’s name, age, occupation: _____________________________________________________________
Those with whom you are now living (list people): ___________________________________________________-
__________
Where you reside: ?house (?own ?rent) ?hotel ?room ?apartment ?other ____________
By whom were you referred? _____________________________________________________________
PRESENTING PROBLEM(s):
Reason for seeking help now: __________________________________________________________________________.
Depression symptoms (check all that apply):
__ Depressed mood most of the day, nearly every day (e.g., sad, empty, tearful);
__ Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day;
__ Appetite/Weight changes: More than 5% change in weight OR decrease or increase in appetite nearly every day;
__ Insomnia or hypersomnia nearly every day; __ Psychomotor agitation or retardation nearly every day;
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 2 of 6
__ Fatigue or loss of energy nearly every day; __ Feelings of worthlessness, excessive/inappropriate guilt nearly daily;
__ Diminished ability to concentrate OR indecisiveness, nearly every day; __Recurrent thoughts of death or suicide.
Anxiety symptoms (check all that apply):
__excessive worry; __restlessness; __easily fatigued; __difficulty concentrating; __mind going blank; __poor memory;
__irritability; __ muscle tension; __sleep disturbance; __GI Sx’s; __headaches; __frequent thoughts of danger;
__avoidance of situations that produce anxiety; __easily startled; __feeling overwhelmed and unable to cope;
__other:___________________________________________________________________________________________.
Obsessive or ritualistic beh/cog which interfere with routine activities? Yes / No _________________________________.
Hx of Panic attacks? Yes / No. If yes, when: _____________________________________________________________.
Panic Sx: Racing heart / sense of terror / sweaty / chills / chest pain, tightness / SOB / loss of control / weakness,
dizzy, faint / tingling or numbness in hands, fingers, limbs
Impulsivity problems? Y / N: spending / sexual / food / alcohol / drugs / video games / gambling/ ___________________.
Hx of manic episode (observable by others; at least one week)? Yes / No. If yes, when: ___________________________.
Grandiosity / decreased need for sleep / more talkative, pressured speech / racing thoughts / easily distracted /
increase in goal-directed behavior / psychomotor agitation / excessive pleasurable risky activity
Are symptoms recurrent/intermittent? Yes/ No ___________________________________________________________.
Frequency/Severity of symptoms: ______________________________________________________________________.
Onset of symptoms: ___ Rapid, as of: _____________________; ___ Gradual, as of: ___________________________ .
PSYCH HISTORY:
Previous counseling: Yes / No. Indiv / marital / family. When/how long?
____________________________________.
Focus/gains?________________________________________________________________________________.
Prior diagnoses: _____________________________________________________________________________________.
Prior psychotropic Rx: _______________________________________________________________________________.
Current psych Rx: ___________________________________________________________________________________.
Family Hx of mental illness/ suicide / substance abuse?
Paternal:________________________________________________________________.
Maternal: _________________________________________________________________.
MINI MENTAL STATUS EXAM: (Check all that apply)
Orientation: ___Oriented to time, place, person, circumstance; ____ Disoriented to _________________________
Psychomotor activity: ___Normal; ___ Accelerated; ___Retarded; ____Restless/Fidgety; ___Rigid posture; _________
Interaction: open / forthcoming / guarded / gamey / oppositional / _____________________________________________
Appearance: Grooming: _____________ Dress: ____________ Weight: _______________; Age: older/younger/as stated.
Eye Contact: good / fair / poor / variable Mood: Today ______________ Past month: _________________________
Speech: normal / loud / soft / slurred / stereotyped / rapid / pressured / extended latencies / __________________________
Affect: congruent / inappropriate / full / labile / blunted / constricted/ flat / ______________________________________
Appears: anxious/ depressed/ manic/ _____________________________________________________________
Thought Process: WNL/ logical / illogical / loose associations / tangential/ circumstantial / paranoid /
suspicious / hallucinations (visual/ auditory/ olfactory/ tactile) / delusions / obsessive /
preoccupation with: ___________________________________________________________________________
Complaints about attention/concentration? Yes / No Complaints about memory? Yes / No
Judgment: Intact / ___________ impairment ______________________ Insight: Poor / Fair / Good
NOTES:
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 3 of 6
SAFETY ASSESSMENT:
Current abuse or violence in the home?
Sexual abuse? Y / N Physical abuse? Y / N Verbal abuse? Y / N Neglect? Y / N
Abuse or neglect involving a child, elder, or disabled person? ___ Denies; ___Yes: _________________________
Current Suicide Risk: ___ Low; ___ Mod; ___ High; ______ Imminent (plan and intent) _______________________
History of prior suicide attempt(s)? Yes / No. If yes, ________________________________________________
History of prior suicide plan with intent? Yes / No. If yes,
_____________________________________________
Violence to Others Risk: ___ Low; ___ Mod; ___ High; ______ Imminent (plan and intent) _______________________
Current homicidal thoughts? Yes/ no. Hx of homicidal thoughts? Yes/ no.
History of violence to others? Yes/ no. If yes, __________________________________________________
Current Substance Use: Current Substance Abuse? Yes / No
Alcohol: ___________________________________________________________________________________
Tobacco: __________________________________ Caffeine: ________________________________________
Cannabis: __________________________________ Other: __________________________________________
Past substance abuse? Yes / No If yes, _________________________________________________________
Self-Harm Behaviors: Denies / Past / Present ___________________________________________________________
Age of onset: _______________________________ Duration: _______________________________________________
Frequency: _________________________________ Location(s) on body: ______________________________________
Severity: __________________________________________ Received Medical Attention? Yes / No
Disordered eating/ body image/ exercise:
History of: binging/ purging / laxatives / diet pills / severe restricting / extreme exercise
Current body image? Excellent Good Fair Poor ______________________________________________________
Current interference in lifestyle or well-being by weight/body/appearance concerns? _______________________________
PHYSICAL HEALTH: Client’s overall rating: Excellent Good Fair Poor
Chronic illnesses: _____________________________________________________________________________
Chronic pain? Yes / No / ________________________________________________________________________
Surgeries: ____________________________________________________________________________________
Current Rx (non-psych): ________________________________________________________________________
Last physical: ____________________________ Name of physician: ___________________________________
Avg physical exercise per week: __________________________________________________________________
Sleep: Avg _____ hrs/night; Insomnia? Yes / no / past / present. If yes: onset / mid / terminal.
Sleep meds used? _____________________________________________________________________
EDUC/OCCUP HISTORY:
Education: Highest grade completed: __________ Advanced degree(s) ____________________________________
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 4 of 6
Schooling: Public/ Private/ Home Learning disability or ADHD? ______________________________
Typical academic performance? Below avg / average / advanced ______________________________
Currently in school? ___ No; ___Yes: _____________________________________________________
Occupation: Currently employed? Yes / No / FT / PT / Job searching. Hrs per week: __________________
Current Emp: ___________________________________________________; ______________ Months / Years
Prior Emp: ________________________________________; _______ Months / Years ____________________
Prior Emp: ________________________________________; _______ Months / Years ____________________
FAMILY:
Grew up where? ____________________________________________________________________________________
Primarily raised by whom? ____________________________________________________________________________
Siblings? _____________________________________ Close with? ___________________________________________
Conflict with? ______________________________________________________________________________________
Current Family/Relationships:
In a committed relationship? ___________________________________________________________________________
Married or cohabiting? Yes / No. Divorced? Yes / No. Previous marriages? Yes / No: _____________________________
__________________________________________________________________________________________________
Children? Yes / No __________________________________________________________________________________
TRAUMA/ABUSE HISTORY:
Emotional/verbal abuse? _______________________________________________________________________________
Sexual abuse/assault? _________________________________________________________________________________
Physical abuse? ______________________________________________________________________________________
Neglect? _______________________________________ Bullying? ________________________________________
Have you ever been in a situation in which you felt you were going to die or be seriously injured? Yes / No
Any significant motor vehicle accidents, head injuries, knocked unconscious, fires/natural disasters? Yes / No
Other experience you would consider “traumatic”? Yes / No.
If yes: ______________________________________________________________________________________
LEGAL HISTORY:
Do you have any past or current involvement with the legal system (e.g., warrants, arrests, detentions, convictions,
probation, parole)? ___________________________________________________________________________________
Do you have any past or current involvement with the court system (e.g., family court, workers compensation dispute, civil
litigation, court-ordered psychiatric treatment)? ____________________________________________________________
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 5 of 6
STRENGTHS/SUPPORTS/LIFESTYLE:
Client’s Perceived Strengths: Ability to articulate: readily / slowly / with great difficulty
1) __________________________; 2) ___________________________; 3) __________________________________
Words that describe your personality: ___________________________________________________________________
Social Support: ____ Sufficient; ____ Limited; ____ Lacking
Primarily supported by: ________________________________________________________________________
Social organizations/groups: ____________________________________________________________________
Conflict in close relationships: Low / Moderate / High ________________________________________________
Hobbies/Leisure Activities: __________________________________________________________________________
Spirituality/Religion: Spiritual resources requested? Yes / No _____________________________________________
Current description/affiliation: _________________________________________________________________________
Raised how? ______________________________ Hx of harmful religious experiences? Yes / No _________________
___________________________________________________________________________________________________
OTHER: Anything we haven’t discussed that you feel I should know about? ____________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What improvements do you hope will result from counseling? ________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Ideas of how long you expect to be in counseling? __________________________________________________________
DIAGNOSTIC IMPRESSION:
Axis I: ___________________________________________________________________________________________
Axis II: __________________________________________________________________________________________
Axis III: (Medical) __________________________________________________________________________________
Axis IV: (Situational) ________________________________________________________________________________
Axis V: (GAF; Current) _____________ Overall symptom severity: mild / moderate / severe / variable
Impairment: Social: _____Little or none; ____Mild; ____ Moderate; ____ Acute/Severe; ___ Variable
Educ/Occup: _____Little or none; ____Mild; ____ Moderate; ____ Acute/Severe; ___ Variable
ADL’s: _____Little or none; ____Mild; ____ Moderate; ____ Acute/Severe; ___ Variable
PLAN:
Sample Unstructured Clinical Interview
© 2016 Laureate Education, Inc. Page 6 of 6
______ Begin psychotherapy w/this author.
Freq/duration: ________________________________________________________________________
Initial Goals/Focus: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____ Other: Recommended: _______________________________________________________________________
Referral: ____________________________________________________________________________
Signed: ___________________________________________ _______________________________
