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Edit Clinical Notes AOHC - Counselling
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Initial Psychosocial Assessment Initial Psychosocial Assessment: g c d e f Family/Social Supports:
Relevant Social History:
Community resources involved:
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Strengths and weaknesses:
Reason for counselling referral:
Clinical Impressions:
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Presenting Problems Presenting Problem: Diagnosis Single episode Recurrent episode Chronic episode
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6 Other: Psychiatric Alcohol/drugs Mania/Hypomania Past suicide attempt Anxiety disorder
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Current Coping Problems
Sleep:
c d e f g
Current living arrangement and suitability: g c d e f Current living arrangement & suitability Comments:
Sleep Comments:
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Appetite: f g c d e Appetite Comments:
Employment/work history: g c d e f Employment/work history Comments:
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Mood:
c d e f g
Contacts with family and friends: g c d e f Contacts with family and friends Comments:
Mood Comments:
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Financial situation: g c d e f Financial situation Comments:
Daily activities/current past activities: g c d e f Daily activities/current past activities Comments:
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Client's Current Perception of Self How does the client describe self:
Interests:
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Dreams and Goals:
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Significant Background Information Family of Origin: (composition, family history):
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6 Relationship history-Children:
Relationship history-Parents:
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Relationship history-Significant Others:
Relationship history-Friends:
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Education: (experiences in school):
Migration history:
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6 Legal history:(CAS Involvement, immigration status
History of Abuse/Violence:
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Medical Health/Psychiatric History
Mental Health History:
Physical Illness History:
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Counselling History:
Use of Substances (alcohol, street drugs, OTC...):
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Mini Mental Exam Appearance normal (dress, grooming, hygiene): Appearance Comments:
c d e f g
Attitude-Calm and Cooperative: Attitude Comments:
c d e f g
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Speech normal (rate/tone/volume without
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pressure): g c d e f
Behaviour normal: f g c d e Behaviour Comments:
Speech Comments:
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6 Thought Processes: Goal-directed and Logical Disorganized
Perception normal (No hallucinations, delusions):
Thought Processes Comments:
Perception Comments:
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6 Suicidal Ideation:
Thought Content: Delusions Phobias Obsessions/Compulsions
None Passive Active
Thought Content Comments:
None Passive Active
5 Suicidal Ideation Active:
6 Affect: Reactive and Mood Congruent Labile Tearful Blunted Normal range Depressed Constricted Flat
Homicidal Ideation Active: Plan Intent Means
Plan Intent Means
Mood: Euthymic Irritable Elevated Anxious Depressed
Affect Comments:
Orientation: Time Place Person Self
Homicidal Ideation:
Mood Comments:
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Insight/Judgement: Memory/Concentration: Short term intact Long term intact Didtractible/Inattentive
Good Fair Poor
Orientation Comments:
Memory/Concentration Comments:
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Depression Assessment Depression Assessment: g c d e f
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Acute Treatment:
Suicide Risk: Assessed Management plan document Self-Management: Goals set and/or Reviewed Follow-up visit (within 7 days)
PHQ-9 (Remission <5): Q1 Score Q2 Results
Q1 Score Q2 Results
Risk Factors for Relapse: Yes (continue meds 2 years)
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(continue meds 2 years)
Planned Follow-up: Weekly Bi-Weekly Other
Other:
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