Generic Mental Health Assessment

1. 
   Before meeting the client:
   

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  Read the referral letter and any other relevant documentation.
  
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  You may choose not to take any documentation (previous notes or referral letter) in session with you, so make a note of the main points.
  
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  Perhaps you would find useful to prepare a general sheet (or index cards) with a structured screening interview guide (headings and prompt questions) and make a note of any specific information you need to find out for the particular client.
  

2. 
   On meeting the client:
   

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  Introduce self by stating your name, professional title and role.
  
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  Ask permission if other people need to be present or observe the interview, introduce them and explain their role, e.g. research, training, supervision, etc.
  
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  Established client’s preferred name.
  
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  Ask permission if the interview needs to be taped, explain and sign a consent form. Keep a copy of the signed consent form and give a copy to the client.
  
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  If the interview is taped, point out the camera/tape recorder.
  
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  Confidentiality: explain who you may share information with and in what form (team meetings, letter to GP, supervision, etc). If client does not want anyone else involved in their care (family, GP, etc) to know details of their treatment, then explain the conditions under which you are allowed to breach confidentiality.
  

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  Explain the purpose and time-scale of the interview.
  
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  Mention what you already know from other documentation.
  
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  Set the agenda COLLABORATIVELY (what you will cover in your interview and in what order).
  
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  Ask the client whether they have anything else to add or ask before you start the interview.
  
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  Explain that you may be taking notes during the interview and the reason for it.
  

Where: Where is it likely to happen more/less? Is it worse in familiar/unfamiliar surroundings?

With Whom: With whom is it better or worse? E.g.: family, friends, crowds, strangers?

When: When is it likely to happen more/less? Does it get worse in the mornings/ evenings?

Feared Consequence/Belief: What is the worse thing you fear would happen if you did/did not…? What is the worst thing for you about having this problem?

Behaviours Identifying the coping mechanisms and safety behaviours

Behavioural Excesses: What do you (do, think, say to yourself) to make you feel better? Are there things that other people do for you that make you feel better?

Behavioural Deficits: What do you do less of to make you feel better? What have you stopped doing? Anything you do less of due to the issue?