Mental Health Counselor Template

Comprehensive Assessment - Headspace

A professional Mental Health Counselor template for healthcare professionals.

About this template

The Comprehensive Assessment - Headspace template is a detailed documentation tool used by mental health counselors to evaluate clients' mental health status. This template facilitates a thorough biopsychosocial assessment, including demographic details, presenting problems, and a comprehensive case formulation. It incorporates the '4 P's' model, mental state examination, and outcome measures to provide a holistic view of the client's condition. Ideal for mental health professionals, this template supports the development of personalized treatment plans and safety assessments, ensuring comprehensive care. It is optimized for use with Heidi, enhancing efficiency and accuracy in clinical documentation.

Preview template

headspace Comprehensive Assessment Date: 2023-10-15 Attendees: Lyndon Stott Confidentiality explained and client questions answered: Yes Mode of referral and relevant background regarding referral: Referred by Dr. Smith due to increasing anxiety and depressive symptoms. Demographics: The client is a 25-year-old female identifying as Caucasian. She holds a bachelor's degree in psychology and works as a marketing assistant. She lives alone in a rented apartment and has a close-knit family of four. Presenting Problem: The client reports experiencing heightened anxiety and depressive symptoms over the past six months, impacting her work performance and social interactions. She describes feelings of worthlessness and difficulty concentrating. Presenting Factors: - Recent job stress - Family history of depression These factors were selected due to their direct impact on the client's mental health and their relevance to her current symptoms. Case Conceptualisation or Formulation: The client presents with symptoms consistent with generalized anxiety disorder and major depressive disorder. Collateral information from her GP and psychometric measures, including the Beck Depression Inventory, support these findings. Observations during the interview indicate a low mood and anxious demeanor. The Other 4 P’s: Predisposing Factors: - Family history of mental illness - Childhood trauma These factors were selected due to their long-term impact on the client's mental health. Precipitating Factors: - Recent job stress - Relationship breakup These factors were selected as they coincide with the onset of the client's symptoms. Perpetuating Factors: - Lack of social support - Maladaptive coping strategies These factors were selected as they contribute to the maintenance of the client's symptoms. Protective Factors: - Strong family support - Access to mental health services These factors were selected as they provide resilience against the client's mental health challenges. Physical Health and Biological Functioning: The client reports no significant medical conditions. She engages in regular physical activity but has poor sleep hygiene and irregular eating patterns. Psychological Functioning: The client has a history of anxiety and depression, with a temperament leaning towards introversion. She employs avoidance as a coping mechanism. Mental State Examination (MSE): Appearance: Neat and well-groomed Behaviour: Cooperative but tense Speech: Soft and slow Mood: Depressed Affect: Restricted Thought Process: Logical but slow Thought Content: Preoccupied with self-doubt Perception: No abnormalities Cognition: Intact Insight: Limited Judgment: Fair Social Functioning: The client has strained relationships with colleagues and limited social interactions outside of work. She is financially stable but feels isolated. Formulation Statement: The clinical impression suggests generalized anxiety disorder and major depressive disorder. Differential diagnoses include adjustment disorder with depressed mood. Global Assessment of Functioning (GAF): The client is rated at 60, indicating moderate symptoms and difficulty in social and occupational functioning. Outcome Measures: - K10: 28 - K10+: 30 - My Life Tracker: 45 - Sofas: 55 - Willingness to Attend: 8 - Clinical Staging: Stage 2, indicating moderate severity and impairment. Personal Safety Risk Assessment: The Columbia-Suicide Severity Rating Scale indicates a low risk of suicide, with no current plan or intent. Agreed Goals: - Client’s stated treatment goals: Reduce anxiety and improve mood - Therapy treatment goals: Develop coping strategies and enhance social support - Timeframes for achieving goals: 3 months Proposed Treatment Plan and Therapeutic Approach: The treatment plan includes cognitive-behavioral therapy (CBT) sessions focusing on anxiety management and mood improvement. Sessions will be held weekly for three months. Single Session Thinking: The client is not suitable for SST due to the complexity of her symptoms. Other Approaches to Consider: Mindfulness-based stress reduction and group therapy may benefit the client. Additional Referrals to Consider: Referral to a GP for a physical health check-up and potential medication review. Clinical Responsibilities: The clinician is responsible for maintaining confidentiality and reporting any risk of harm to self or others as per Australian law. Coping Plan: Healthy Coping: - Regular exercise - Mindfulness meditation Unhealthy Coping: - Avoidance of social situations - Excessive alcohol consumption Crisis and Safety Plan: Warning signs include increased isolation and negative self-talk. Actions include contacting a trusted friend and seeking immediate professional help. Emergency contacts include Lifeline and the client's GP. Safe Engagement: Ensure regular check-ins and provide a supportive therapeutic environment. Headspace Comprehensive Assessment Summary: The treatment plan is designed to be flexible, allowing for adjustments based on the client's progress and feedback. It aims to address the client's anxiety and depression through evidence-based interventions, with a focus on building resilience and enhancing social support. Lyndon Stott

headspace Comprehensive Assessment Date: [Insert Date] Attendees: Lyndon Stott Confidentiality explained and client questions answered: Yes Mode of referral and relevant background regarding referral: [Insert referral background] Demographics: [Provide a detailed introduction about the client’s demographics including their age, gender identity, cultural identification, education level, occupation, family size, living arrangements, and any other relevant information.] Presenting Problem: [Complete a detailed biopsychosocial assessment for the presenting problem.] Presenting Factors: - [Insert presenting factor] - [Insert presenting factor] [Provide justification for why these factors were selected.] Case Conceptualisation or Formulation: [Include collateral information, observations, psychometric measures, and details from the interview with the client. Provide a detailed paragraph summarizing all relevant information.] The Other 4 P’s: Predisposing Factors: - [Explain what a predisposing factor is and list predisposing factors here.] [Provide justification for why these factors were selected.] Precipitating Factors: - [List precipitating factors here.] [Provide justification for why these factors were selected.] Perpetuating Factors: - [List perpetuating factors here.] [Provide justification for why these factors were selected.] Protective Factors: - [List protective factors here.] [Provide justification for why these factors were selected.] Physical Health and Biological Functioning: [Provide a detailed report on the client's genetic vulnerabilities, neurological functioning, substance use, medical conditions, medications, physical activity, sleep, nutrition, etc.] Psychological Functioning: [Report on the client's psychological functioning, including information on trauma, temperament, coping skills, and mental health history.] Mental State Examination (MSE): Appearance: [Insert details] Behaviour: [Insert details] Speech: [Insert details] Mood: [Insert details] Affect: [Insert details] Thought Process: [Insert details] Thought Content: [Insert details] Perception: [Insert details] Cognition: [Insert details] Insight: [Insert details] Judgment: [Insert details] Social Functioning: [Provide detailed information on the client's work, study, family relationships, romantic relationships, socioeconomic status, etc.] Formulation Statement: Clinical impression, preliminary presentation, diagnosis (if relevant), and differential presentations: [Provide a rigorous case formulation, including evidence and significant justification.] Global Assessment of Functioning (GAF): [Describe GAF and the rationale for the assigned rating. Detail factors involved in assigning the specific rating.] Outcome Measures: - K10: [Insert score] - K10+: [Insert score] - My Life Tracker: [Insert score] - Sofas: [Insert score] - Willingness to Attend: [Insert score] - Clinical Staging: [Insert rating and explanation] Personal Safety Risk Assessment: [Conduct a personal safety risk assessment using the Columbia-Suicide Severity Rating Scale. Provide detailed justification for selected metrics.] Agreed Goals: - Client’s stated treatment goals: [Insert goals] - Therapy treatment goals: [Insert goals] - Timeframes for achieving goals: [Insert timeframes] Proposed Treatment Plan and Therapeutic Approach: [Develop and report a detailed treatment plan and session agenda for a maximum of three sessions. If not suitable for SST, provide justification.] Single Session Thinking: [Indicate whether the client is a suitable candidate for SST and provide justification.] Other Approaches to Consider: [Identify other evidence-based approaches or activities that may benefit the client.] Additional Referrals to Consider: [Recommend other relevant professional referrals, such as GP or Nurse Practitioner, and explain the rationale.] Clinical Responsibilities: [Detail the treating clinician’s legal responsibilities and mandatory reporting obligations in Australia.] Coping Plan: Healthy Coping: - [Insert healthy coping behaviors] Unhealthy Coping: - [Insert unhealthy coping behaviors] Crisis and Safety Plan: [Provide a detailed crisis and safety plan including warning signs, actions, and contact names/numbers.] Safe Engagement: [Express actions to ensure safe client engagement.] Headspace Comprehensive Assessment Summary: [Summary of the treatment plan, explaining its flexibility and adaptability] (This section must be highly detailed and output in paragraph format) [Clinician name] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)

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