Psychiatric diagnoses are complex due to their varied presentations, and an absolute diagnosis may not be made within the first few visits.
However, the initial consultation is crucial for outlining the path of assessment and treatment. While every provider has a unique approach to the initial evaluation, we generally cover similar essential information.
Our first session with clients is 60 minutes and includes clinical formulation and treatment recommendations. As you’ll see, there is a lot to cover, and information gathering is an ongoing process. This ensures we gather comprehensive information to support our clients effectively.
Here’s a breakdown of the information we typically collect:
History
We begin by discussing the specific problems or concerns that led to the visit, as well as any stressors that may have precipitated the visit.
Past Psychiatric History
This section covers any previous episodes similar to the current presentation, including past treatments, medications (with details on doses and duration), instances of dangerous behavior, self-harm, suicide attempts, and any prior hospitalizations.
Family History
We review the medical and mental health history of parents and
siblings to understand potential genetic predispositions or family patterns.
Substance Use
This involves a thorough review of alcohol and illicit drug use, as well as any history of over-the-counter medication abuse.
Medical History
We collect contact information for the client’s primary care physician and discuss any current or past medical problems and complaints. We also inquire about any history of head injury, particularly those involving loss of consciousness, memory loss, seizures, or surgeries.
Social History
This broad area evaluates various aspects of the client’s life, including relationships with significant others, school-related issues (such as learning problems or
special needs), legal and behavioral challenges, and work/career concerns. We also explore individual and family strengths, interests, and relevant cultural and religious
factors.