Therapist's Guide to Clinical Intervention - Sigmund Freud

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A: Measurable Behavioral Goals with Target Dates for Resolution 1. 2. 3. B: Planned <strong>Intervention</strong>s 1. 2. 3. C. Objective Outcome Criteria by Which Goal Achievement Is Measured 1. 2. 3. D. Progress Since Last Update E. Referrals F. Discharge Planning Comments: 492 4. Professional Practice Forms <strong>Clinical</strong> Forms Business Forms
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Therapist's Guide to Clinical Inter
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Therapist's Guide to Clinical Inter
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CONTENTS Introduction xvii Level of
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Chapter 2 ASSESSING SPECIAL CIRCUMS
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Evaluation and Disposition Consider
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Ten Ways of Responding to Aggressio
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Low Self-Esteem 330 The Self-Esteem
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Couple's Conflict: Rules for Fighti
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Insured/Responsible Party Informati
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INTRODUCTION THIS second edition, l
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Level of Patient Care and Practice
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Levels of Functioning and Associate
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The Treatment Plan formulation serv
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*HIPAA: Health Insurance Portabilit
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COMMON AXIS 1 AND AXIS 2 DIAGNOSES
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Treatment Focus and Objectives 4. D
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Dual Diagnosis (developmentally dis
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E. Proceed in treatment plan with t
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In cases where ADHD is suspected, f
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C. Role-model and practice communic
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Additional Considerations D. Use ve
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Additional Considerations 3. Excess
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Additional Considerations B. Teach
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EATING DISORDER (EDO) Due to the ov
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G. Encourage appropriate separation
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Additional Considerations 13. Self-
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Obsession with Weight Obesity and S
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IDENTITY DISORDER This disorder is
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CHILDREN When working with children
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Freud's constructs of psychosocial
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DEMENTIA D drug interaction E emoti
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7. Risk for Injury A. Assess 1. Psy
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D. Systemic illness 1. Substance in
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shaping of a new identity integrati
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3. Setting limits and boundaries 4.
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LIST OF SYMPTOMS LEADING TO RELAPSE
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44 Common Drugs of Abuse (Continued
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B. If this has been an ongoing case
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how to respond to the various side
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1. Diagnosis A. Schizophrenia B. Br
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Goals Treatment Focus and Objective
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E. Evaluate impaired social interac
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8. Weight loss or gain 9. Priapism
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MANIA Goals 1. Provide safe environ
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J. Identify and focus on positive a
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2. Culture may influence under diag
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B. Moderate to severe depression: w
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Treatment Focus 1. Assess for Refer
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E Irrational Beliefs 1. Identify fa
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It is evident that unless cognitive
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SOMATOFORM DISORDERS The central fe
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B. Encourage independent fulfillmen
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. Scholarly reading c. Independent
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DISSOCIATIVE DISORDERS 2. Somatizat
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SEXUAL DISORDERS 5. Identity Distur
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the intensity of the stressor. Inst
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Medication might be utilized as a s
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not often present for treatment of
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PERSONALITY DISORDERS B. Facilitate
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B. Facilitate identification of fee
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I. Facilitate the use of thought st
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7. Overly Sensitive A. Facilitate i
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Treatment Focus and Objectives 5. M
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Goals Treatment Focus and Objective
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3. Dramatized Social Interaction A.
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3. Increase awareness for intensity
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PHYSICAL FACTORS AFFECTING PSYCHOLO
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Medical Causes of Psychiatric Illne
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This page intentionally left blank
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Outline of the Interview 1. Succinc
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STRUCTURED INTERVIEW FOR DEPRESSION
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Subjective Patient Review of Self A
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6. social support (lack of support
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118 2. Assessing Special Circumstan
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Risk History Explain any significan
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CYCLE OF PHOBIC ANXIETY Physiologic
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5. Inadequate Coping A. Consequence
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TRANSPORTATION Assess ability to ef
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CRISIS EVALUATION The crisis evalua
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4. What was the person feeling and
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PAIN IDENTIFICATION CHART Name Date
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7. Positive feedback and reinforcem
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3. Feeling high after vomiting or s
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EATING DISORDER EVALUATION: BULIMIA
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ADULT ADD SCREENING 174 2. Assessin
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B. Social (Description of peer asso
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CHEMICAL DEPENDENCY PSYCHOLOGICAL A
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Preliminary Treatment Plan: List pr
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186 Chemical Use History Check if u
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C. If the victim remains in the rel
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C. Modalities 1. Support group 2. P
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Tertiary Prevention Indicators of P
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Likewise parent(s) or caretaker(s)
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CHILD CUSTODY EVALUATION REPORT OUT
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Specify treatment recommendations,
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11. Eating disorders 12. Entitlemen
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Because the court monitors such pla
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C. History of mental health problem
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COMPULSORY PSYCHOLOGICAL EVALUATION
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REPORT OUTLINE COMPETENCY 1. Interv
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momentum to get things going and in
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STRESS MANAGEMENT 9. Evaluate the p
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7. Unable to say "no." 8. Trouble l
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ASSERTIVENESS To assert oneself pos
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2. Stop procrastinating A. Be hones
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period of regular use, they find th
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HOW TO GET THE MOST OUT OF YOUR DAY
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RELAXATION EXERCISES 3. Self-motiva
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ecreate a relaxing place, perhaps a
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In a perfect state of relaxation yo
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Now, focus your attention on your h
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STEP 1:. Preparation and Determinin
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PREPARING TO LEARN PROBLEM-SOLVING
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ASSIGNMENT 1 ASSIGNMENT 2 SAMPLE PR
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RISKS Nothing ventured, nothing gai
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1. Describe your feelings prior to
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IMPROVING COMMUNICATION SKILLS Less
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ASSERTIVENESS INVENTORY The followi
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NONVERBAL COMMUNICATION Rationale:
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PERSONAL BILL OF RIGHTS ASSERTIVENE
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D. Clarify what it is that you want
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THE COMMUNICATION OF DIFFICULT FEEL
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them to symbolically take your hand
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infuriated cross worked up boiling
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DECISION MAKING 11. Be prepared to
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SETTING PRIORITIES Once you have se
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Explore Your List of Stressful Thou
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Steps to Successful Refraining For
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8. Be honest and true to myself. 9.
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DEFENSE MECHANISMS Defense mechanis
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As with other things that are negat
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HANDLING ANGER 9. What are your goa
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2. Take time out 3. Exercise or do
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had tripled in 15 years. Therefore,
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17. Acts of violence 18. Sees self
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third party trained to deal with su
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Talk, don't argue. Arguing increase
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ADJUSTING/ADAPTING Some Common Life
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LEARNING HISTORY 1. What did you le
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3. They have been taught that if th
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GRIEF Grief is intense emotional su
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ACCEPTANCE This is the last stage o
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IS LIFE WHAT YOU MAKE IT? JOURNAL W
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DEVELOPING AND UTILIZING SOCIAL SUP
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HOW TO BUILD AND KEEP A SUPPORT SYS
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MANAGING DEPRESSION 9. Ask for help
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decide what you are going to do. Th
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UTILIZING YOUR SUPPORT SYSTEM EXAMP
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. participating in pleasurable acti
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DAILY ACTIVITY SCHEDULE DATE: MOOD(
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DEPRESSION When a person experience
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FEELING LIKE YOUR LIFE IS OUT OF CO
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If I hide myself through fear, envy
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LOW SELF-ESTEEM some medications ca
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THE SELF-ESTEEM REVIEW Directions:
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AFFIRMATIONS FOR BUILDING SELF-ESTE
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CHARACTERISTICS OF LOW SELF-ESTEEM
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CHARACTERISTICS OF HIGH SELF-ESTEEM
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practice could take place specifica
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Resources that I am aware of that w
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FATIGUE OR SLEEP DEPRIVATION There
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POST-TRAUMATIC STRESS DISORDER (PTS
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Now that you know that beliefs affe
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SURVEY OF STRESS SYMPTOMS Check eac
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25 WAYS TO RELIEVE ANXIETY 1. Posit
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11. Utilize your support system. If
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WARNING SIGNS OF RELAPSE 1. negativ
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WHAT IS DEMENTIA? 8. Have the indiv
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SYMPTOMS OF PERCEPTUAL DISTURBANCE
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TEN WARNING SIGNS OF ALZHEIMER'S DI
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4. Cope with what needs to be done
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TIPS FOR THE CARETAKEE 1. Obtain th
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TEN TIPS FOR BETTER SLEEP People su
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HEALTH INVENTORY Use the following
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ASSUMING THE PATIENT ROLE: THE BENE
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4. Exercise A 40-year-old sedentary
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EATING HISTORY B. It may be overloo
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5. Be assertive about how you feel
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DEALING WITH FEAR 4. Do not focus o
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5. Be careful to guard against feel
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their behavior. Without this insigh
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LIST OF SYMPTOMS LEADING TO RELAPSE
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THE CLASSIC SITUATION The codepende
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As children they feel many things;
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2. I can't tell where my reality en
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poor coping, poor problem solving,
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RELATIONSHIP QUESTIONNAIRE This que
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This behavior tends to escalate und
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3. Decide ahead of time if you plan
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safe and together. Women often beli
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4. It is not fair to interrupt. Sta
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4. Don't hold back waiting to see h
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6. Use active listening behaviors (
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12. The goal of the family meeting
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Losses such as death, divorce, relo
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child experiences a crisis parents
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14. Does the child feel that life i
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Accept the child as a unique indivi
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SURVIVING DIVORCE 6. tied to choice
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SUCCESSFUL STEPFAMILIES Differences
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5. Be emotionally available to your
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THE RULES OF POLITENESS SELF-MONITO
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5. Goal: Objective:. ACCOMPLISHMENT
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3. Let go of the past. If you can't
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4. Relevant history of presenting p
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9. Diagnostic tests A. There may be
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Is there a history of sexual abuse
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1 MENTAL STATUS EXAM 2 3 4 5 6 Prob
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MENTAL STATUS EXAM Appearance: Groo
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Memory Impaired Not impaired Immedi
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DIAGNOSIS: AXIS I: AXIS IV: AXIS II
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IV V D. Observations about other fa
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Mood and Affect Mood: normal anxiou
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LIFE HISTORY QUESTIONNAIRE The purp
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I. List your five main fears: 1. 2.
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D. Did you ever experience any anxi
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F. Give a description of your mothe
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B. What feelings do you wish to alt
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6. Any history of abuse (emotional,
Page 992: SUMMARY This year old (include sex,
Page 996: Problems perceived to be: very seri
Page 1000: 3. 4. 5. 6. Others living in the ho
Page 1004: normal weight gain _Yes _No was chi
Page 1008: ADDITONAL COMMENTS: Therapist Date
Page 1012: 34. Clingy and in need of constant
Page 1016: BRIEF MEDICAL HISTORY Name: Age: DO
Page 1020: MEDICAL REVIEW CONSULT REQUEST FOR
Page 1024: 6. What medication(s) are you curre
Page 1028: SYMPTOMS (If Yes, Please Explain) Y
Page 1032: Effects of on Family/Support System
Page 1036: INITIAL EVALUATION CONSULTATION NOT
Page 1040: BRIEF CONSULTATION NOTE TO PHYSICIA
Page 1046: Therapist Date Patient Outpatient T
Page 1050: Fear of doing something uncontrolla
Page 1054: 2. Intervention and/or Teaching: 3.
Page 1058: SOCIAL SECURITY EVALUATION MEDICAL
Page 1062: DISABILITY STATUS Patient discharge
Page 1066: Percepion Hallucinations: None, aud
Page 1070: BRIEF LEVEL OF FUNCTIONING REVIEW F
Page 1074: What are the treatment plan target
Page 1078: OUTLINE FOR DIAGNOSTIC SUMMARY DIAG
Page 1082: DISCHARGE SUMMARY NAME OF PATIENT:
Page 1086: Bwsmess Forms 513
Page 1090: PATIENT REGISTRATION (PLEASE PRINT)
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CONTRACT FOR SERVICES WITHOUT USING
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LIMITS ON PATIENT CONFIDENTIALITY W
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CONTRACT FOR GROUP THERAPY 1. As a
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CLIENT MESSAGES In-Chart Log Client
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REFERRAL FOR PSYCHOLOGICAL Evaluati
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RELEASE TO RETURN TO WORK OR SCHOOL
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DUTY TO WARN Although confidentiali
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RECEIPT RECEIPT Date of service: Na
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BALANCE STATEMENT Date Name Our rec
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8. Treatment ended with this therap
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QUALITY ASSURANCE REVIEW Patient Nu
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BIBLIOGRAPHY Ackerman, R., & Michae
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Bepko, C, & Krestan, J. A. (1985).
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Drabman, R. S., Spitalnick, R., & O
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Hackett, G., & Horan, J. J. (1980).
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Lazarus, R. (1966). Psychological s
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Othmer, E., & DeSouza C. (1985). A
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Washton, A. M. (1995). Psychotherap
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INDEX A Abuse neglect and child abu
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management scale 161 six stages of
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contract for group therapy 521 cont
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R Rational thinking realistic self-
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other ways 302 what are the myths o
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