Our initial assessments follow a similar basic structure.
The first, and most important, part of our evaluation is taking down the patient history. We want to understand the problems that have lead up to your visit and any precipitating stressors. We will also perform a review of the symptoms you have experienced.
We will discuss any past psychiatric history This section covers any past episodes or symptoms similar to the recent one and any past treatments, including medications used and responses. We find it helpful to know dosage information and amount of time on the medication. We also look for past dangerous behavior, self-harm behavior or suicide attempts and past hospitalizations.
Family medical history is also important. Medical and mental health problems with parents and siblings are reviewed, as well as issues extended family has faced. Genetics play a strong role in mental health problems.
Any other relevant medical history is obtained, such as:
- Substance abuse- review of alcohol and street drug use, along with a history of over-the-counter medications
- Developmental history- birth history is reviewed, and history through childhood and onward
- Medical history- contact information of primary physicians, history of vision and hearing problems, history of head injuries, any surgeries
- History of menses and pregnancy history- sexual history is also evaluated if needed
- Social history- issues with parents, kids, siblings and overall home life, issues with significant others, legal problems, school issues, peers and social supports, ongoing stressors, work and career issues, driving and transportation problems for teens, and cultural or religious issues
Appearance, interaction, speech behavior, mood, affect and other characteristics may be used as an informal cognitive assessment by your provider.
*There may be a waiting period between your intake phone call and your assessment appointment.