What is wrong with me? Why do I feel sad or hopeless all the time? Why can’t I concentrate? How can I cope with this overwhelming worry? I can’t sleep well anymore, is something wrong with me? These are just a few examples of the questions that our diagnostic evaluation seeks to help you answer.
As you may imagine, psychiatric problems can be difficult to diagnose due to the complex interactions of different factors that makes each of us different and unique in our own way. Some of these factors may be genetic, biological, social, or environmental.
Despite this complex interplay of factors influencing mental health, our comprehensive, diagnostic psychiatric evaluation will help simplify some of this complexity. This evaluation will answer some of the questions that will help start your journey towards healing.
Our diagnostic evaluation is about 60 minutes in length, and at minimum it covers the following:
History of present Illness
This is the chance to describe the problem(s) that led up to the visit and any precipitating stressors.
Past Psychiatric History
This covers any past episodes similar to the recent one, past treatment including medications used and responses (it is very helpful to know doses and amount of time on the medications), past dangerous behavior, self-harm behavior or suicide attempts, and any past hospitalizations.
Family History
Medical and mental health problems with parents and siblings are reviewed. This may also include a family history of drugs, alcohol, substance use and addictions.
Substance Use/Addictions
A review of alcohol and illicit drug use, along with history of over-the-counter medication abuse. Also touches on an addictions or addictive behaviors.
Medical History
Contact information for the client’s primary care physician. A review of any current or past medical problems and medical complaints is also conducted. Next, there is a review of any history of head injury, especially an injury with loss of consciousness, memory loss, seizures, or surgeries.
Social History
This history evaluates functioning in many areas of life including Issues with significant others. School issues, including history of learning problems or special needs. Legal problems and behavior problems. Work/career issues. Individual and family strengths and interests. Cultural and religious issues
Often, an absolute diagnosis is not made even in the first few visits. The first visit, however, is very important in clarifying the path that assessment and treatment will take. Every provider has his or her own system for the initial evaluation, but we all generally cover the same information.
We meet with adults for 60 minutes for the first session, which includes a clinical formulation and treatment recommendations. As you will see, there is a lot to cover in the first session and the assessment and collection of information is an ongoing process.
What To Bring
If applicable: Current medication bottles, prior mental health records, current medical records, work history, academic records.
