INTERVIEW FORM FOR PSYCHOLOGICAL ASSESSMENT OF RELAPSE

PATIENTS

FILE NO.

Date

Name Sex

Date of Birth Age

Marital Status: S/ M D/ W / Sep

Present Address

Permanent address

Phone

Education Occupation

Siblings: M F

Birth Order

Father’s Name Father’s Age

Father’s Education Father’s Occupation

Mothers Name Mothers Age

Mother’s Education Mothers Occupation

Spouse’s Name Spouse’s Age

Spouse’s Education Spouse’s Occupation

Children (Sex/Age)

Family Structure (Nuclear/ Joint)

Head of Family__________ Earning Members

Income Group ___________ Heritage

Languages

Appearance
Informant’s Name Informant’s Relationship

Informant’s Phone/Address

Referred by
How severe, on a scale of 1-10 (with 1 being the most severe), do you rate your presenting problems?

(Highest) 1 2 3 4 5 6 7 8 9 10 (Lowest)
1 Presenting Problems
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________________________________________________

2 History of problems

3 Recent losses

Family Member Friend Health Lifestyle Job Income Housing None

Who? _______________________________ When? _________________

Nature of Loss? _______________________________

Other Losses: ______________________________________________

4 Prior treatment

5 Alcohol/ Drug Assessment

Current or past history of alcohol/drug use? Yes No

If Yes, complete table below. If no history, move to next section.
Do you ever drink or use more than you intend to? Yes No
If yes, how often: Almost every time occasionally Seldom More often lately
when under stress Other: _______________
Do you have a history of overdosing on alcohol/drugs? Yes No
If yes, when was the last OD? ___________
Have you ever experienced a black out? Yes No
If Yes, how often: Almost every time occasionally Seldom More often lately
when under stress Other: _____________
 With whom do you typically consume alcohol? Friends Family N/A‐Alone
Strangers Other
Have you ever experienced problems related to your alcohol use? Yes No Legal
Social/Peer Work Family Friends Financial
Have you continued to drink/use drugs? Yes No

6 Medical history

Please List any Psychiatric medication you have taken or are taking:

Medication Date Side Effects Benefits

7 Family history

8 History of Abuse/ Neglect

Have you ever been abused or assaulted? Yes No

If yes, please complete the chart below.
Sexual Yes No
Physical Yes No
Emotional Yes No
Verbal Yes No
Abandoned/Neglected Yes No
Abuse by Whom? ________________________________
At What Age? ____________________________________
Was it reported? __________________________________

Do you feel like you are in danger now? Yes No

What else do you feel is important for us to know? ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

9 History of violence
Have you ever been accused of abusing or assaulting someone? Yes No
If yes, please complete chart below.
Sexual Yes No
Physical Yes No
Emotional Yes No
Verbal Yes No
Abandoned/Neglected Yes No
Abuse to Whom? __________________________________________
At What Age? _____________________________________________
Was it reported? ___________________________________________
What else do you feel/believe is important for us to know? ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

10 School history (marks/divisions, relationships with peers and teachers, extra -

curricular activities)

11 Work history (nature of job and interaction with colleagues)

12 History of friendships (nature and extent)

13 Orientation (person, place, time)

14 Attention (concentration, memory)

15 Perception ( illusions, delusions, hallucinations)

16 Thought (any disorganization or loosening of association)

17 Affect ( crying spells, guilt, depression, suicidal, hostility, grandiosity)

18 Behavior (speech: mute, talkative, abusive, motor: restless, destructive, excited,

motor retardation)

19 Posture (unusual gestures)

20 Anxiety (tension, phobias, obsessions/compulsions)

21 Psychosomatic ( obesity, headache, painful menstruation, asthma, ulcers, skin

disorders, vomiting, nausea)

22 Family psychopathology ( nature, history, treatment of any mental disorder of any

member)

23 Interview behavior (open, withdrawn, cooperative, timid, aggressive, complaint)

24 Relapse Related Questions

1. Do familiar surroundings and people sometimes seem strange, confusing, threatening to you?

2. Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?

3. Do things that you see appear different from the way they usually do?

4. Have you had experiences with telepathy, psychic forces, or fortune telling?

5. Have you felt that you are not in control of your own thoughts and actions?

6. Do you have strong feelings or beliefs about being unusually gifted or talented in some way?

7. Do you feel that other people are watching you or talking about you?

8. Have you been dishonest to yourself?

9. Have you ever felt that you don't exist, the world does not exist, or that you are dead?

10. Have you been confused at times whether something you experienced was real or imaginary?

11. Do you hold beliefs that other people would find unusual or bizarre?

12. Are you financially stable?

13. Do you feel that parts of your body have changed in some way, or that parts of your body are
working differently?

14. Are your thoughts sometimes so strong that you can almost hear them?

15. Do you find yourself feeling mistrustful or suspicious of other people?

16. Do people sometimes find it hard to understand what you are saying?

17. Do you feel that you are not accepted by the society?

18. Do you fantasize or become over confident about things?

19. Do you accept the realities of life easily?

20. Have you completed your previous medical/therapeutic treatment?

21. You experience good or poor social support?

22. Any other problems you are facing these days or in the near past?
 25 Psychiatric/Psychological History
Are you currently being seen by a counselor? Yes No
If yes, name of current counselor ___________________________
Length of Treatment _____________
Are you currently being seen by a psychiatrist? Yes No
If yes, name of current psychiatrist __________________________
Length of Treatment _____________
Have you ever been diagnosed with a mental health, emotional or psychological condition?
Yes No
If yes, what diagnosis were you given? ___________________________________
When? __________________________________________________
By Whom? ________________________________________________

26 Strengths/ Resources/ Support

What limitations do you have (if any)?____________________________________________________
What strengths do you have? _____________________________________________________________
What resources do you have to help with your current problem? _________________________________
__________________________________________________________

What experiences (past & present) will help you in improving the current situation? _________________
_____________________________________________________________________________________
_______________________________________________________________________________
What are you (and your family) already doing to improve the current situation? _____________________
______________________________________________________________________
Who can you count on for support? Parents Spouse Siblings Extended Family
Friends Neighbors School Staff Therapist Group Community Services
Doctor Other: _____________________________

27 Current needs/ Goals

What do you feel is your biggest need right now? _____________________________________________
What do you most hope to gain from coming to counseling? _____________________________________
_____________________________________________________________________________________
If you were to pick three goals to work on, what would they be?
Goal 1: _______________________________________________________________________________
Goal 2: _______________________________________________________________________________
Goal 3: _______________________________________________________________________________

28 Tentative diagnosis / date

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29 Recommendations

_______________________________________________________________________________________________________

30 Final diagnosis / date

___________________________________________________________________
31. Termination (unilateral, bilateral)/Date

31. Reasons for termination