Therapy Soup Blog on the Evaluation Process

Amazon Bestseller, NAMI (National Alliance of Mental Illness) Advocate Book Pick, Dec., 2009

From Therapy Revolution (HCI Books), Chapter 4, Focus on Your First Appointment, Page 90

For Therapy Patients, Their Families, and Support Networks: You need to be prepared for every step of therapy, from finding a therapist, to the first few visits, to the very last session, and beyond. Become an educated patient and you will get more effective treatment.

During your first or second psychotherapy session, your therapist will ask you plenty of questions (and write down all your answers) in order to get to know as much as possible about you. These questions are collectively known as the Evaluation or the Biopsychosocial History. This and other useful checklists, charts, and questionnaires are included in Therapy Revolution, along with easy-to-understand tips and pointers, real-life patient interviews, and more.

Biopsychosocial History/Evaluation Checklist
[When your therapist does your evaluation], make sure that at least the following topics are included in the questions he or she asks:

• 1. Identifying data/demographic data (social security number, date of birth, sex, race, emergency contact information, living situation)
• 2. Alcohol and drug history (including over-the-counter and prescription medications, herbal or nutritional remedies, and illegal drugs and alcohol; how drugs are administered; frequency of use; age first used; date last used; progression of use; withdrawal symptoms; history of treatment programs/hospitalizations; symptoms and complications of alcohol and drug history)
• 3. Mental health history (including medication history and compliance, allergies to medications, history of treatment programs/hospitalizations, and symptoms and complications of that history, including harm to self or others)
• 4. Medical history (including medication history and compliance, allergies to medications, hospitalizations, chronic and/or life-threatening illnesses, and symptoms and past and current complications of that history)
• 5. Other topics (sexual history, educational history, vocational history, financial history, legal history, social history, family/significant other, gambling history, nicotine history, eating disorders, spirituality, leisure, military history)
• 6. Reason for seeking treatment
• 7. Questions specific to present stage of life (childhood, adolescence, geriatric, etc., as needed)