The Total Evaluation

On the right hand column of this web site and blog you will notice an Evaluation Checklist,  excerpted from my book. In response to your emails, I’v excerpted the general definition of the evaluation and also included the checklist again. This is from Therapy Revolution, (HCI Books), page 83 and page 90.

The Biopsychosocial History/Evaluation

Not too far into your first session, usually right after you tell the therapist why you came to see him, the therapist will begin to do an evaluation—an initial and/or ongoing assessment of a patient’s clinical status that will be used to develop a plan for treatment. The evaluation primarily includes a large body of information called the biopsychosocial history. This evaluation will help him gather specific information about you, including biographical, psychological, and social information (in far more detail than just general questions) and will help him understand you better. It will help him develop a detailed treatment plan based on your individual needs.

The therapist should write down your answers to the evaluation questions. Virtually any therapist who does not do a comprehensive written evaluation—unless you have given him permission to tape-record the information instead—or take detailed notes during sessions will be unable to remember important details about you. A psychotherapist is required to keep written treatment records of each patient. This is not only to facilitate treatment, but also for insurance reasons, in case he is asked by you to turn the case over to another doctor for medical reasons, or in case you want copies of your own records, which you are entitled to by law. If your therapist is not writing notes during (and after) your session, the chances are his treatment records will be sparse. Also, he will be unable to go over those all-important notes in order to refresh his memory before his next session with you. This will make treatment decisions very difficult.

Biopsychosocial History/Evaluation Checklist

Make sure that at least the following topics are included:

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)