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
      • When?
      • How?
    • Hospitalization/Outpatient tx
      • ECT
      • Injectables
    • 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?

Diagnosis Tree [Click here to continue]