Beruflich Dokumente
Kultur Dokumente
Marital Status:_Divorced__________________
2
History of family psychiatric treatment or counseling: No__X__
Yes_____ Explain:
Dates:___________________
Circumstances:
N/A
Were you abusing drugs or alcohol during the time of the attempt(s)?
No_____ Yes______
N/A
What kind of treatment did you receive?
N/A
Family history of suicide or attempts: No_____ Yes_______
N/A
Relationship:___________________________
Question for family member:
3
What is your understanding of the reason(s) for the clients attempt(s)?:
N/A
Health/Medical_____
Psychiatric_____
Legal_____
Occupational_____
4
Interpersonal_Divorce everyone hates me____
General appearance:
Disheveled, not put together, bruises on her arms and hands.
often_____ Explain:
Ability to abstract:
Memory: Intact_____; Difficulty with: Recent events_____ Remote events______
6
Test recent memory with 3 objects in a 5 minute exercise (when needed)
Thought processes: Logical _____ Relevant_____ Coherent_____
Does patient look stated age? Yes_____ No______; Older_____ Younger_____
8. Medical history
During the past 6-12 months, have you had changes in the following:
Sleeping patterns? No_____ Yes__X___
Describe:
I like to sleep a lot, but sometimes I
cant sleep because all I can think about
is reasons why I should die.
Appetite? No_____ Yes__X__
Describe:
I dont eat much whats the point.
Weight? No_____ Yes___X__
Describe:
But it doesnt matter because Im always going to be ugly.
Concentration patterns? No_____ Yes__X__
Describe:
All I can think about is dying
Energy Level? No_____ Yes__X__
Describe:
The only energy that I have is enough energy to figure out how I am going to
kill myself.
Libido? No__X__ Yes_____
Describe:
7
I dont have anyone to have sex with so it doesnt matter, if you must know!
Mood? No_____ Yes_X___
Describe:
Im sad, mad, angry, dont care.
Current medical treatment: No__X__ Yes_____
Explain:
None but maybe I should get some to help speed up the process.
Current medication(s): No__X__ Yes_____ List any below with dose/times
None but maybe I should get some to help speed up the process.
List all herbal medications (e.g., St. Johns Wort, Kava Kava) or
complementary therapies (i.e.
acupuncture)
N/A
Surgical procedures during the past 12 months: No__X__
Yes_____ Explain:
8
N/A
9. Family/Social/Work History:
Describe your living situation (number of people in the household, own
home/rent/ other)
I live by myself and I rent. Nobody wants to be around me, everyone always
leaves.
Do you feel safe in your current living situation? Explain:
Does it matter, Im going to die anyway.
Have you ever been a victim of abuse from a family member? Explain:
Not really. I just get yelled at a lot as a kid, I could never do anything right,
ever.
Have you ever been a victim of abuse from other? Explain:
N/A
9
None
Evaluation of reading ability? Any special needs that we need to be aware of?
OVERALL IMPRESSIONS: