Substance Use History
Discuss substance use as it relates to the age of the client when first using alcohol, marijuana, cocaine, and other substances. Also, explore abuse and dependence history and factors that sustain use. Discuss the client’s treatment history and any family history of substance use and treatment. Discuss frequency of present use, how it began, what sustains it, periods of sobriety, factors contributing to sobriety (external or internal), obstacles to success with sobriety, family history, previous attempts at treatment, number of relapses, perception of use difficulty, awareness of relapse potential, awareness of risk factors for relapse, and triggers to use and relapse.
Medical History
Review all relevant medical history, medications, and treatments. Explore family medical history.
Objective Testing
Identify the full name of each test, and include descriptions of the purposes for each one used in the assessment.
Example
Tests administered
Minnesota Multiphasic Personality Inventory, second edition (MMPI-2)
The MMPI-2 is a self-administered personality inventory designed to evaluate personality traits and symptoms of psychological illnesses and personal maladaptive adjustment.
Weschler Adult Intelligence Scales, fourth edition (WAIS 4)
The WAIS 4 is a full-scale intelligence test used to identify intellectual functioning and potential deficits in both verbal and non-verbal areas.
Findings
Relate your findings in the format recommended by the test manual. Incorporate your findings with your observations of the client and the self-descriptions the client offered during the interview. Also, include test findings as they relate to collateral information on the client.
Diagnostic Impressions
Using the latest version of the Diagnostic and Statistical Manual of Mental Disorders provide your diagnostic impressions that may include subtypes, specifiers or rule outs.
Conclusion
Summarize your findings by incorporating interview data, test data, collateral information, and mental status elements. Discuss your findings as they relate to your observations of the client and the referral question and purpose of the assessment.
Recommendations
Discuss your recommendations as they relate to the referral question, treatment needs, third party request, and the purpose of the assessment.