Clinical Notation: Documentation for clients in treatment - CASAT

Assessment• A basic assessment consists of gathering key information andengaging in a process with the client that enables the counselor tounderstand the client's readiness for change, problem areas, CODdiagnosis(es), disabilities, and strengths. Intake information oftenconsists of• Background—family, trauma history, history of domestic violence(either as a batterer or as a battered person), marital status, legalinvolvement and financial situation, health, education, housingstatus, strengths and resources, and employment• Substance use—age of first use, primary drugs used (includingalcohol, patterns of drug use, and treatment episodes), and familyhistory of substance use problems• Mental health problems—family history of mental health problems,client history of mental health problems including diagnosis,hospitalization and other treatment, current symptoms and mentalstatus, medications, and medication adherence