This is just one sample of an assessment. This is taken from a corrections environment, but the questions are not much different for any evaluation. All the key elements are discussed. Section V addresses substance-abuse issues. It is a quick evaluation of potential substance problems, which will trigger the need for further assessment by the drug and alcohol program of the facility as seen in the recommendations. From here, there may be more than one treatment plan. While the outpatient plan will include AOD (alcohol and other drug) treatment, the drug and alcohol program will most likely add an addendum or include its own so that all providers are aware of how each is planning to assist the client. Psychological Evaluation (prison) Dictation Date: XXXXX Institution: CCI Inmate Name: XXXX Inmate #: xxxxxx Date of Birth: XXXXXXX Referral Source: X Self Medical Recovery Services Segregation MH Initial Screening Education Housing Unit MH Detailed Job Assignment Screening Parole Board Religious Services Other: Screening in Seg. Administration Rules Infraction Board Inmate Housing at Time of Referral: (check one) X General Population Segregation Infirmary (not crisis bed) Other: Crisis Bed I. Reason for Referral: (Presenting Problem) Inmate kited Mental Health because he was feeling depressed. Inmate was referred for a psychological evaluation to determine level of care. II. History of Present Illness 1
Inmate states that he has been depressed since incarceration approximately 1-year ago because he buried his mother the day before he was locked up. He was also married 1 week prior to incarceration and has not heard from his wife since this time. He reports multiple physical ailments, which are causing him increasing distress. His heart doctor gave him 5 7 years to live, the 7th year being the current year. He reports that he sleeps most of the time except to eat and go to pill call. He stated that this is his favorite time of year because he loves sports and has become apathetic toward following games this year. He further stated that he has lost his job, his home, his family, and his health and is unable to think of anything else. He is fearful of being released in 1 year because he has no means of support. His depression seems to be building as his release is approaching. He states that he has lost the ability to redirect his thoughts to anything positive. He has recently started crying for no reason when he watches T.V. that occurs during commercials as well as regular programming. III. Psychiatric History (In-patient/Out-patient treatment; include current medication if any) Inmate reports that he was evaluated by a counselor for SSI once and saw a couple of counselors in previous incarcerations. He states that he has never received inpatient hospitalization treatment for mental illness. IV. Medical History: Include current medications HBP on meds but unsure which ones, 2 heart attacks resulting in one procedure for a 5 bypass heart surgery given 5 7 years to live with current year being #7, diabetes (15 years) taking insulin, Hepatitis C, neuropathy in legs (3 4 years), deteriorated disc in spine from the neck down, deteriorated rotator cuff in right shoulder, lost right index finger to spider bite in 2001, two concussions as child. V. Alcohol & Substance Use History: Inmate states he drinks alcohol socially. He likes to drink beer with his buddies on the weekends and sometimes in between. He used cocaine and heroin as a young adult and was clean 10 + years; however, in the last 5 years he states using these drugs 1x/month or less. Frequency was daily until incarcerated. VI. Personal History (including Hx of physical and or sexual victimization/abuse) Inmate denies any history of physical and or sexual victimization/abuse. 2
VII. Social History States he is a high school graduate, but the records indicate he has a GED. States he played baseball, football, and basketball. He had many friends throughout life. Currently, he has no social supports, especially upon release. VIII. Occupational History He made his living mostly as a truck driver from 1981 1996. He sold his rig just prior to moving from Florida to Ohio to assist and live with his ill mother. IX. Family History He is an only child who never knew his father. His aunts and uncles are old, ill, or deceased. Since he lived in Florida, he has not had any contact with cousins. He reports that his mother was a kind and nurturing parental figure who was loved by everyone. X. Criminal Justice History (current conviction and sentence, prior arrests and convictions) Current: Drug trafficking, cocaine. Priors: 2002 Drug Trafficking, 1974 80, 3 offenses: 1 probation violation XI. Institutional Adjustment Fair; while he has not been a problem for the institution, he has been minimally engaged in activities. XII. Mental Status Examination A. Appearance & Behavior Hygiene adequate; eye contact indirect, looks away most of the time, tearful at times; slow gait possibly due to problems with legs. B. Mood & Affect Depressed with congruent affect C. Speech & Language Soft, slow, low tones. Language appropriate and easy to follow. D. Thought Process Connected, logical, and coherent 3
E. Thought Content & Perceptions No abnormal or bizarre perceptions; however, he is intently focused on the negative aspects of his life. F. Cognitive Assessment Average, with some reported memory impairment, stating he could not recall his wife s name yesterday although he has known her 20 years. He states that he sometimes goes someplace and forgets why he went. He states he is becoming increasingly scatterbrained. He fears that history of abusing drugs could have caused these problems. G. Suicide/Violence Risk Assessment Past Suicidal Ideation/Attempts (date & method) Inmate denies suicide attempts. He states he sometimes wishes he would not wake up in the morning. Current Suicidal Ideation/Behavior Inmate denies especially because he would probably mess it up, and this would just add to his problems. Past Violent/Assaultive Behavior, including sexual assault Inmate denies. Present Ideas/Behavior Inmate denies. H. Insight/Judgment Inmate has limited insight and judgment due to overwhelming medical and emotional issues. XIII. Psychological Testing Results GAMA 90, BDI-II 38, severe (8-30-06) XIV. Diagnostic Impression Axis I: 296.2 3 Major Depressive D/O, moderate, Polysubstance Dependence Axis II: V71.09 No diagnosis on Axis II 4
Axis III: Left index finger partially cut off from spider bite, HBP on meds, deteriorated spine and right shoulder rotator cuff, diabetic on insulin, Hepatitis C, neuropathy in legs Axis IV: Incarceration, death of mother, loss of family supports Axis V: GAF: 60 XV. Treatment Recommendations (including medications, labs ordered) Admit to the outpatient mental health caseload, consult with the psychiatrist for medication therapy, supportive counseling 2x/month to address unresolved grief and depression, participate in Thinking Errors Group, and continue to monitor symptoms of depression for possible RTU admission. Referral to Drug and Alcohol program for further evaluation and assessment for services. Disposition (check one): x General Out-Patient Caseload Psychiatric Out-Patient Caseload Residential Treatment Unit Crisis Bed Next Appointment: Probate Sex Offender Caseload No Further Services Required x Other: Refer to psychiatry Name, Title and Signature of Evaluator: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Signature: Goals Goals are usually created with the client. In some agencies, this is put in the client s own words. In others, there is a list of goals that are to be used to provide consistency within the agency. A goal is described in terms of an achievable outcome. The question from solution-focused therapy is a good 5
place to start. You might ask the client if he or she wants to be free of symptoms what that look would like. How long do you reasonably think this will take? Usually goals have been written with 3 month increments and are evaluated by the client and the therapist at the end of this period. However, this can vary depending on the requirements of the funding source. Some require a cap on therapy sessions, and others require goals in increments to show progress. There are usually 2 3 goals for a client s plan. These can be anything from reducing the duration and intensity of the symptoms of a mental illness like depression to maintaining sobriety or anything in between. Objectives These are the actions the client and therapist will take to assist the client in achieving their goals. Typically there are 2 3 objectives for each goal, but there can be more or less depending on the needs of the client. For example, for the first goal discussed above, you might require some of these objectives: 1. Meet with counselor 1X per week for 1hour for CBT therapy. 2. Participate in depression group 1X per week for 2 hours. 3. See psychiatrist for medication. 4. Participate in art therapy 1X per week. 5. Client will walk for ½ hour per day. In the second goal, you might use these objectives: Attend alcohols group daily, group therapy 1x per week, and meet with psychiatrist for medication evaluation. Client s Strengths Identification of the client s strengths is important in building a strong bridge to a functional life. This is usually done during the interview or evaluation and is part of the treatment plan. How will the client use his strengths to follow through with the plan? For example, a client might be creative and using his artistic ability in an art therapy group can be helpful in moving toward wholeness. Another strength might be persistence or assertiveness. You might have a goal of gaining employment through the use of the objectives by writing a resume, researching jobs, and going on a particular number of interviews. These need to be measurable. Other Needs 6
Becoming gainfully employed, dealing with the legal system, building social networks for support, and spiritual needs are all important to the well being of the client. These can be met through referrals to outside sources for assistance if the agency does not provide these types of assistance. 7