Intake, Assessment, and Diagnosis Notes

Flashcards covering key terms and definitions related to intake, assessment, and diagnosis in mental health counseling.

A comprehensive evaluation of a client’s functioning across biological, psychological, and social domains to inform diagnosis and treatment planning.

Biopsychosocial Assessment

Standardized assessment tools with predetermined questions to ensure consistency and diagnostic accuracy.

Structured Interviews

A structured assessment of a client's current psychological functioning based on observation and direct questioning.

Mental Status Examination (MSE)

The process of comparing similar conditions to determine the best-fitting diagnosis.

Differential Diagnosis

The presence of more than one disorder at the same time in a client.

Co-Occurring Disorders

Specific time frames required to meet the diagnostic criteria for various mental disorders.

Common Minimum Duration by Diagnosis

An evidence-based therapeutic approach focusing on identifying and modifying maladaptive thought patterns and behaviors.

Cognitive-Behavioral Therapy (CBT)

A client-centered therapeutic approach aimed at enhancing intrinsic motivation for behavior change by resolving ambivalence.

Motivational Interviewing (MI)

A process to evaluate an individual's potential risk for suicide based on various psychological, social, and behavioral factors.

Suicide Risk Assessment

Strategies used in therapy to improve client outcomes, including cognitive, affective, and behavioral approaches.

Therapeutic Techniques

A therapeutic approach that explores unconscious conflicts, emotions, and relational patterns to promote insight and healing.

Psychodynamic Therapy

A therapeutic approach that helps individuals find personal meaning in life.

Logotherapy

A therapeutic approach that examines family dynamics and structures to improve communication and relationships.

Family Systems Therapy

A psychological treatment that helps individuals confront their fears and reduce anxiety.

Exposure Therapy

Includes appearance and behavior, speech, mood and affect, thought process and content, perception, cognition, insight, and judgment.

Mental Status Exam Categories

Identifiable personal strengths, coping abilities, and support systems that can enhance resilience during treatment.

Strengths and Protective Factors

A model that describes the phases individuals go through when making behavioral changes, including precontemplation, contemplation, preparation, action, and maintenance.

Stages of Change

The stage in which individuals are not yet considering change and may be unaware of their issues or the need for change. They often deny or minimize the problem. (struggling to think they have a problem)

Pre-Contemplation

The stage in which individuals are aware of their issues and start to think about making a change. They may weigh the pros and cons but have not yet committed to taking action. (Answers will have words like ask, explore, determine, clarify, assess, gather, survey, inquire)

Contemplation

The stage in which individuals intend to take action soon and may begin making small changes. They create a plan and set goals to prepare for taking significant steps toward change. (Answers will have improve, increase, decrease, help, reduce)

Preparation

The stage in which individuals actively implement their plans to change their behavior and take concrete steps towards achieving their goals. This involves consistent effort and self-monitoring to maintain progress. (Answers will have a verb like referral, discussion, facilitate, describe)

Action

The stage in which individuals work to sustain the changes they have made over time. This involves ongoing efforts to prevent relapse and ensure that new behaviors become ingrained in their lifestyle. (client has tools needed to actively change their behavior long-term)

Maintenance