Psychology - Any type of Depressive Disorder
4. Adjustment Disorder
A description of the content for each of the main sections of the Psychosocial History is as follows: Include relevant aspects of the person’s history and development as related to the referral question. Do not add anything that is not absolutely necessary to the referral question. When appropriate cite source of information and any inconsistencies in the report. This is the introduction, why the client is being tested, how they ended up in the situation they did, what their current symptomology is presenting as, its form and severity. Identifying Information · Client’s name, age, marital status, ethnicity, gender. · Reason for testing at this time. · Specifics about symptomology during this episode, all pertinent symptomology related information including onset, duration, frequency, severity, impact, course, and efforts at managing. · How did the client get to the current level of care or intervention? · What efforts have been made to manage the symptoms? Developmental History · Relates to prenatal and early childhood maturation, development, injuries. · Include discussion of developmental milestones. Medical and Psychiatric History · History of Psychiatric and Physical Health/Illness, support known diagnosis by making certain you support (or refute) diagnosis by specifying symptomology. · History of illness (onset, duration, severity, level of impairment, highest level of functioning, course, chronic vs. acuteness of symptoms). · Efforts at managing · Relevant history of health problems or lack of problems. In the event of no previous history of any psychiatric illness and physical health status has been unremarkable, you would have nothing to comment except this point: “The client’s health history is reported to be otherwise unremarkable.” · Include history of hospitalizations and any drug or alcohol abuse. Academic and Employment History · Include what kind of grades clients earned throughout school. · How did they like school? · Did they have problems in school? · Level of education? · What job did they hold? · Can they hold a job? · When they have a job, do they advance or stay in the same position? · Current occupation? Mental Status Exam