DSM 5: Intake Diagnostic Interview
Background / Client Statement of Presenting Problem
- Introductions (listen for):
- Speech / Thought: Vocabulary, phrasing, mood, affect.
- Tonsoria: cleanliness/neatness, stylish, appropriateness/match, pleasing/jarring/provocative/modest/cloaking/bland/brash/affected/natty/dowdy, smell.
- Executive Functions: Planning story, anticipating needed detail, communicating mood, tracking response to story, adjusting story to fit listener, salience of detail.
- Expression: Tangential, pressured, flight of ideas, repetitive, losing train of thought, confabulation, grandiosity
- Body Language: stiff, emotive, wild, safe, protected, closed, open
- Background
- History of presenting illness (as reported by client or referring professional/caregiver
- Past psychiatric history (as reported by client, caregiver or paperwork)
- Start of symptoms
- First seek treatment
- Full recovery in past
- Hospitalization/Outpatient tx
- Medications
- Dose(s) / Start date(s), Stop Date(s)
- If stopped why?
- Current medications with doses
- Side Effects experienced
- Counseling history
- Start date(s), Stop date(s)
- If stopped why?
- Safety (as reported by client or caregiver)
- Frequent or troubling thoughts of harming yourself or others
- History of suicide
- Date of most recent attempt
- Number of Attempts
- Methods
- Tx given
- Frequency of being so upset that you make or even act on threats of violence to other people, animals or property
- Aggressive, Deceptive, Destructive Behaviors (road rage, lying to hurt people, smashing things)
- When (and precipitating conditions)
- What
- History (as reported by client, caregiver or paperwork)
- Past medical history
- Allergies
- Family history
- Developmental history
- Social history
- Mental Status (assessment by observation)
- Appearance
- Behavior
- Speech
- Mood
- Affect
- Thought Processes
- Thought Content
- Cognition/Intellectual Resources
- Insight / Judgement
- Follow-up (with client and/or caregiver)
- Thanks
- Is there anything important that I should have asked about or that I missed?