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1) Introduction
(Name, age, ethnicity, sexual orientation, occupation, relationship, children, current social circumstances, address, phone number, ethnicity)

2) Presentation
(nature of referral, including client's definition of presenting problem[s] and expectations of help).

3) Alcohol and Drug History
a Which substances used in life, including caffeine and nicotine (ever, at least 10x, at least 10x in a month)

b Pattern of substance use, including amount (first use, first regular heavy use, first withdrawal symptoms, recent use, last use, inventory of last five days use, heaviest periods of use, longest periods of abstinence)

c Context: setting, supply, money spent on use, route of administration

d Complications of alcohol and drug use

e Dependence / abuse status (using standardised questions for alcohol, cannabis and then for other drugs)

f Treatment history (including use of self-help groups)

g Risks of harm: direct and indirect ie sharing needles, unsafe sex.

h Corroborative material: screening tools, professional reports, reports from significant others; diary or journal etc

4) Current Prescribed Medications (psychiatric and medical, including dose)

5) Psychiatric/Psychological History
a Past diagnoses/treatment.

b Screening of current and lifetime diagnosis of the following:

i. Generalised anxiety disorder: Have you ever worried a lot about terrible things that might happen, even when it was unrealistic to worry as much as you did?

ii. Social phobia: Is there anything that you were ever afraid to do or felt uncomfortable doing in front of other people, like speaking, eating or writing? What were you afraid could happen when?...

iii. Agoraphobia: Were you ever afraid of going out of the house alone, being in crowds, standing in a line, or travelling on buses or trains? What were you afraid could happen?

iv. Panic Disorder: Have you ever had a panic attack, when you suddenly felt frightened, anxious or extremely uncomfortable? Have you ever had one when you didn't expect to at all?

v. Post-traumatic stress disorder: Have you ever experienced a very traumatic event that was extremely distressing?

vi. Anorexia nervosa: Have you ever had a time when you weighed much less than other people thought you ought to weigh and when you continued to feel overweight?

vii. Bulimia nervosa: Have you ever had eating binges during which you ate a considerable amount of food in a short period of time and during which your eating was out of control?

viii. Obsessive compulsive disorder: Have you ever been bothered by thoughts that didn't make any sense and kept coming back to you even when you tried not to have them? Was there ever anything that you had to do over and over again and couldn't resist doing, like washing your hands again and again or checking something several times to make sure you had done it right?

ix. Dysthymic disorder: Have you ever been bothered by depressed mood most of the day, more days than not, for a period of several years?

x. Major depressive syndrome: Has there ever been a period of time when you were feeling depressed or down most of the day nearly every day? (As long as two weeks?)

xi. Manic syndrome: What about ever having the opposite of depression when you were feeling so good or high that other people thought you were not your normal self or you were so high that you got in trouble?

xii. Pathological Gambling: Have you ever gambled or bet too much?

xiii. Delusions (reference and persecutory): Did it ever seem that people were talking about you or taking special notice of you? What about receiving special messages from the TV, radio or newspaper, or from the way things were arranged around you? What about anyone going out of their way to give you a hard time, or trying to hurt you?

xiv. Hallucinations (auditory and visual): Did you ever hear things that other people couldn't hear, such as noises, or the voices of people whispering or talking? Did you ever have visions or see things that other people couldn't see?

• Exploration of self-harm, harm to others or harm from others, suicidality (ie previous attempts, include thoughts or actions), homicidality (past/current).

6) Medical History
a Past diagnoses/treatment

b Current symptoms/problems in systematic review (nervous, endocrine, CV, respiratory, GI, GU, skeletal)

c Estimated risk of infection (esp Hep B, Hep C, HIV)

d Attitude to health and healthy activities

e Validation

f Medical check-ups/ laboratory results

7) Legal/Forensic History

(Convictions, jail terms, charges pending, current legal status)

8) Family History

a Structure of family of origin

b Family disorders (alcohol and drug, psychiatric, medical and legal in first and second degree relatives).

c Living in the family while growing up (including general family functioning, adequacy of specific relationships within family and occurrence of physical/sexual abuse)

d Current relationships (with members of family of origin)

e Genogram

9) Personal/Developmental History

a Significant life events in infancy.

b Relationships outside family of origin (from childhood through to the present, including psychosexual development and marriage, key enduring friendships, sexual orientation, cultural identity) NB It may be best to avoid exploration of sexual abuse in the initial assessment.

c Education (include literacy) and work(from school through to the present).

d Personality (including description of patient and the presence of conduct disorder, attention-deficit-hyperactivity disorder, antisocial personality disorder [using standardised questions] and any other personality disorders — only use clients labels).

e Loss, trauma, grief, abuse (more generally)

10) Current Psychosocial Functioning (Work, relationships, accommodation, finances, social networks, ongoing stresses, coping skills, problem-solving skills)

a Social networks use of substances

b Leisure/social activities

c Resources and strengths

d Coping and problem solving skills

11) Motivation for Change
a Client's reasons for using substance/ functional analysis

b Reasons to consider changing this

c Stage of change on wheel of change

d Validation — if tool used to assess stage of change


1.Appearance and Behaviour (physical appearance, clothing, movements, state of intoxication, state of consciousness)

2. Speech
(speed, articulation, volume, relevance)

3. Affect and Mood

(Signs of depression, elation, anxiety)

4. Thought Process

(specific thought disorder)

5. Thought Content

(preoccupations, overvalued ideas, delusions)

6. Perception

(illusions, hallucinations)

7. Insight/Motivation? Readiness to Change

(Degree of awareness/acceptance and ability to co-operate with treatment, stage of readiness to change)

8. Cognitive Screening
("I'm now going to ask you a routine set of questions related to memory and concentration.")

a. Orientation: (Time/Place/Person) year, season, month, day, date, time

b. Registration: four unrelated objects

c. Attention and Concentration: "100-7 test"; spell world backwards

d. Naming of Objects: name watch strap, clasp and tell time

e. General Knowledge:
Prime Minister of New Zealand
Capital City of Australia
Closest planet to the sun

f. Interpretation of a Proverb concrete/abstract

g. Constructional Ability: draw a clock face

h. Short-term Recall: of the four unrelated objects


1. Summary

2. Diagnosis (using first three Axes of DSM-IV multiaxial system)
Axis 1 Alcohol and drug
Additional psychiatric
Axis 2 Personality
Axis 3 Physical conditions

3. Problem List

a. Current stressors/issues (physical health, mental health, work, family, relationship, accommodation, financial, legal, any other)

b. Level of functioning (current/past year)

4. Formulation

The formulation is an explanatory statement. It attempts to answer a key clinical question: "why is this person presenting in this way at this time?" It is a statement that links individual characteristics and issues (past and present) to diagnoses in a way that generates treatment goals and management plans.

(2x4 grid may help in organizing ideas: Bio-psycho/Socio-environmental x Predisposing/Precipitating/Perpetuating/Protecting factors)


1. Management Goals

2. Management Plan
Eight keys areas to address:

1. More information required

2. Setting

3. Treatment of medical conditions

4. Psychopharmacology

5. Psychological intervention

6. Family/Social/Occupational

7. Education of Patient and Significant Others

8. Self-help group
All of the above considered over the short term as well as the long term.

3. Prognosis

a. Natural course of the illness

b. +ve factors that modify the course in this patient

c. —ve factors that modify the course in this patient

d. Synthesis and prediction (symptoms and general functioning)


1. Introduction (Introduction and Presentation)

2. Alcohol and Drug History (Alcohol and Drug History)

3. Psychiatric and Medical History(Current medications, Psychiatric history, Medical history)

4. Other Relevant History(Legal/Forensic, Family, Personal/Developmental History)

5. Mental State Examination (Mental State Examination)

6. Opinion (Summary, Diagnosis, Problem List, Formulation)

7. Management (Management Goals, Management Plan, Prognosis)

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Comprehensive Management and Treatment Plan
Case Study of Rose

Case Background
Rose, a 35- year- old Maori woman was referred to my medical centre with symptoms that were indicative of diabetes. Although Rose’s physical appearance suggested that she is Maori yet she introduced herself as a New Zealander. She mentioned that she was raised in a traditional setting; however, she does not want the health care professionals to include her family or any of the Maori stuff in her treatment procedure. Interactions with her revealed that she was ashamed of her community and thus did not want us to associate her health issues with that community. She was reluctant to share any of the Maori stuff with me and thus I approached the Whanau to gather Rose’s personal and medical history. Careful mental health assessment revealed that Rose was suffering from depression. She also reported of delusions regarding her dead uncle. She also complained of mood disorder. None of her behaviour raised suspicion that she might be suffering from psychiatric disturbances. She also reported that she had moved away from her whanau because she was ashamed of them. However, upon establishing contact with her sister, who is very supportive, she started missing them. However, her sister cannot actively participate in her treatment because of the demands of her own whanau and work. She wished for me to help her with her depressions, mood swings and in managing her diabetes.
Following a number of interview sessions, Rose admitted that she was highly dependent on alcohol. Upon conducting a DSM4 AUDIT, which is a gold standard method to calculate the extent of abuse, I found that Rose consumed > 15 standard alcohol units per week. Moreover, after substance abuse, she frequently dreams of her dead uncle visiting and has witnessed him on the streets several times. The alienation from her whanau and Te Ao Maori led her to substance abuse and low mood. In the past, she never sought help to get rid of her drinking problem or depressions and mood swings. However, Rose was neither harmful to herself or others. Since, Rose has symptoms that were indicative of diabetes,therefore, at the initial stage, I planned to put Rose on a diabetic diet to maintain her weight and regular exercise profile. For relieving her from depression and mood swings, I refered her to a GP who prescribed her on a daily dose of Celexa (30 mg)(Quinn, 2015). Since Rose dreamt about her dead uncle visiting her and witnessed her uncle walking on the streets only after heavy drinking, it is evident that she suffered from delusions and/ or hallucinations because of substance abuse. In a number of cases, it has been reported that excessive substance abuse can result in depression and delusions. To help her overcome her dreams about her dead uncle I referred her to Karakia sessions. I also suggested her...

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