Evaluations

Evaluations 2017-10-26T14:42:16+00:00

A Family Assessment is an assessment of the safety and overall functioning of you and your family to guide recommendations for treatment and other intervention services. It typically includes the person served and caregivers (which may include biological parents, step-parents, or legal guardians) in the home.

Who Can Complete: A mental health practitioner (LIMHP, LMHP, Psychologist, etc) with training and experience in family dynamics and therapy. The practitioner may be associated with a family intervention such as IFP (Intensive Family Preservation).

What this evaluation should include:

  • Presenting Problem/Reason for Referral
  • Family Structure
  • Family History
  • Educational/Employment History of caregivers
  • Current Living Arrangements
  • Family Dynamics and Functioning
  • Household Rules and Structure
  • Safety Concerns
  • Family Mental Health/Substance Abuse History
  • Family Strengths/Assets
  • Concerns/Liabilities
  • Summary and Recommendations

When to refer:

  • When the concern is about the quality of family relationships and/or the adequate functioning of the family to protect and nurture children.

Summary: A Family Assessment is an assessment of the safety and overall functioning of you and your family to guide recommendations for treatment and other intervention services.

An Initial Diagnostic Interview (IDI)/Mental Status Exam (MSE) is a brief screening of a client’s mental functioning in the areas of affect, mood, and cognitive ability. May be used to identify specific psychological testing needs.

Who Can Complete: A psychologist, psychiatrist, or licensed independent mental health practitioner (LIMHP).

What this evaluation should include:

  • Screening of Client’s Mental Functioning
  • Risk Assessment regarding potential to hurt self and/or others
  • Diagnosis
  • Clinical formulation (the professional’s insight into your past and current strategies)
  • Future treatment recommendations

​Tips for your first visit:

  • So that you don’t forget, you may want to write down a list of symptoms you are struggling with.
  • Remember to be honest.
  • Bring along any medical or mental health records you feel would be helpful.
  • If you are anxious, it may help to ask a close friend or family member to come be a support for you.

When to refer:

  • Utilized with other assessments to determine appropriate diagnosis and treatment recommendations. Typically completed in conjunction with a Mental Health Evaluation.

Summary: An Initial Diagnostic Interview (IDI)/Mental Status Exam (MSE) is a brief screening of a client’s mental functioning in the areas of affect, mood, and cognitive ability.

Your Content Goes HereAn Integrated Substance Abuse and Mental Health Evaluation combines features of a Mental Health Evaluation and a Substance Abuse Evaluation. Increasingly, it has been seen the population of those with mental health disorders and those with substance abuse disorders overlap significantly.

Who Can Complete: A dually credentialed clinician who is either a Licensed Independent Mental Health Practitioner (LIMHP), a Licensed Mental Health Practitioner (LMHP), or a Provisionally Licensed Mental Health Practitioner (PLMHP) AND a provisionally or fully licensed alcohol and drug counselor (LADC or PLADC) with adequate training, education, and credentials.

What this evaluation should include:

  • Presenting Problems
  • Demographics
  • Medical History
  • Social/Work/School/Military history and functioning
  • Detailed substance use history (when it started, how it progressed and current status)
  • Legal history
  • Family and social history, including past and current exposure to violence/trauma
  • History and current mental health concerns
  • Past Treatment History
  • May include rating on ASAM criteria (American Society on Addiction Medicine)
  • Mental Status Observations including suicide or violence risk
  • Collateral information from referring party, family members, and other providers is ESSENTIAL to a good evaluation
  • Diagnosis
  • Clinical formulation (the professional’s insight into your past and current strategies)
  • Future treatment recommendations

​Tips for your first visit:

  • So that you don’t forget, you may want to write down a list of symptoms you are struggling with.
  • Remember to be honest.
  • If you are currently on prescription medications, it may be helpful to provide a list to the clinician.
  • Bring along any medical or mental health records you feel would be helpful.
  • If you are anxious, it may help to ask a close friend or family member to come be a support for you.

When to refer:

  • Whenever there are concerns of both a mental health and substance abuse disorder.

Summary: An Integrated Substance Abuse and Mental Health Evaluation combines features of a Mental Health Evaluation and a Substance Abuse Evaluation.

Your Content Goes HereA Mental Health Evaluation (also known as a Biopsychosocial Assessment [BPSA] or Pretreatment Assessment [PTA]) is a detailed interview of your presenting problems and symptoms, functioning, history, and treatment issues and needs. Typically completed in conjunction with an Initial Diagnostic Interview (IDI)/Mental Status Exam (MSE).

Who Can Complete: Typically conducted by a Licensed Mental Health Practitioner (LMHP) or Independent Mental Health Practitioner (LIMHP).

What this evaluation should include:

  • Presenting Problems
  • Demographics
  • Medical History
  • Social/Work/School/Military history and functioning
  • Detailed substance use history
  • Legal history
  • Family and social history, including past and current exposure to violence/trauma
  • History and current mental health concerns
  • Past Treatment History
  • Mental Status Observations including suicide or violence risk
  • Collateral information from referring party, family members, and other providers is ESSENTIAL to a good evaluation
  • Diagnosis
  • Clinical formulation (the professional’s insight into your past and current strategies)
  • Future treatment recommendations

​Tips for your first visit:

  • So that you don’t forget, you may want to write down a list of symptoms you are struggling with.
  • Remember to be honest.
  • Bring along any medical or mental health records you feel would be helpful.
  • If you are anxious, it may help to ask a close friend or family member to come be a support for you.

When to refer:

  • A Mental Health Evaluation is a logical starting point as a referral if there are any concerns about mental health related functioning.

Summary: A Mental Health Evaluation (also known as a Biopsychosocial Assessment [BPSA] or Pretreatment Assessment [PTA]) is a detailed interview of your symptoms, functioning, history, and current mental status.

A Parental Fitness or Capacity Assessment is a specialized psychological evaluation to assess the capacity of a parent to parent their children. A Parental Fitness or Capacity Assessment typically includes psychological testing, clinical interviews, and parent/child observations.

Who Can Complete: A Licensed Psychologist. This is a forensic examination and it is important that the evaluator is impartial and not aligned with either side.

What this evaluation should include:

  • Presenting Problem
  • Safety Concerns
  • Collateral Information
  • Standardized testing
  • Clinical Formulation
  • Diagnosis
  • Treatment Recommendations

When to refer:

  • When there are serious questions about permanency for the child.
  • When a parent has shown minimal progress toward an acceptable level of capacity.
  • At any point in a case where the parent’s impairments or problems are so severe that there is a question of their ability to make progress.

Summary: A Parental Fitness or Capacity Assessment is a specialized psychological evaluation to assess the capacity of a parent to parent their children.

A psychiatric evaluation is a clinical interview which allows a psychiatrist to get to know you, the symptoms you are experiencing and how you have tried to cope with them. It is of utmost importance the psychiatrist have an understanding of your history and current symptoms, which may include reviewing past records or speaking to those involved in your life. The average length of time for your first appointment may vary but is typically between 40-90 minutes.

Who Can Complete: A psychiatrist is a medical doctor or an APRN (Advanced Practice Registered Nurse) with specialized psychiatric training.

What this evaluation should include:

  • Presenting Problems
  • Demographics
  • Medical History
  • Social/Work/School/Military history and functioning
  • Detailed substance use history
  • Legal history
  • Family and social history, including past and current exposure to violence/trauma
  • History and current mental health concerns
  • Past Treatment History
  • Mental Status Observations including suicide or violence risk
  • Collateral information from referring party, family members, and other providers is ESSENTIAL to a good evaluation
  • Diagnosis
  • Clinical formulation (the professional’s insight into your past and current strategies)
  • Assessment of whether medication is needed
  • Future treatment recommendations

​Tips for your first visit:

  • So that you don’t forget, you may want to write down a list of symptoms you are struggling with.
  • If you are currently on medication, it may be helpful to provide a list to the psychiatrist.
  • Bring along any medical or mental health records you feel would be helpful.
  • If you are anxious, it may help to ask a close friend or family member to come be a support for you.

When to refer:

  • When you or your client has complex and significant mental health symptoms and high risk behaviors.
  • When you or your client has had other mental health evaluations (MsE, Psychological, etc.) but there is a question of whether the diagnosis is accurate.
  • When you or your client has not shown progress in an appropriate level of treatment (example: therapy).
  • When medication management is suggested as part of the treatment plan.

Summary: A psychiatric evaluation is a clinical interview which allows a psychiatrist to get to know you, the symptoms you are experiencing and how you have tried to cope with them.

A psychological evaluation provides detailed insight into the cognitive, emotional, and behavioral functioning of a patient, including a comparison to what is normative given the age and other status of the patient. It may be used to determine specific educational or treatment needs and/or to provide differential diagnosis when a patient’s treatment or progress may have reached an impasse.  A psychological evaluation is conducted by an individual with a doctoral degree in clinical, counseling, or school psychology.   A psychologist is not a medical doctor and cannot prescribe medication.   The evaluation consists of a face to face interview of a patient, as well as assessment using one or more standardized measurement instruments, depending on the purpose of the evaluation and the specialty of the evaluator. In addition, review of records and interview of important collateral sources (parents for example) is usually indicated.  For those reasons it is important for the referring professional to be very clear about the reason for testing and the specific questions that need to be answered.

Who Can Complete: Licensed Psychologist

What this evaluation should include:

  • Diagnostic Interview determines nature of problem and what specific testing is indicated
  • COLLATERAL INFORMATION from referring party, family members, other providers is ESSENTIAL to a good psychological evaluation
  • A battery of standardized tests are administered in accordance with the needs identified in the referral question and from the diagnostic interview.*
  • Clinical Formulation: this statement is a synthesis of test results and a statement of the implications for the client and should give insight into the nature of the
  • client’s problem
  • Diagnosis (DSM IV — DSM 5)
  • Specific treatment recommendations as relevant to the referral question.
  • Risk assessment in regard to patient harm to self or others – if applicable
  • Prognosis: the likely outcome of treatment
  • *Testing may include the following:
    • Intelligence tests measure basic cognitive capacities such as thinking, understanding concepts, acquiring information, solving problems, and reasoning.
    • Personality tests measure basic personality style, which is generally considered to be stable over time. Well-known examples are the Minnesota Multiphasic Personality Inventory (MMPI), or the revised MMPI-2, and the Millon Clinical Multiaxial Inventory-III (MCMI-III).
    • Neuropsychological tests measure specific areas cognitive functioning including attention, memory, executive functioning, and language. Often assess deficits in these areas that may result from brain damage, such as a stroke or a brain injury.  Learning disabilities, for example, may affect the brain’s ability to receive and process information
    • Occupational tests:  match interests of the person with  interests of persons in known careers. Examples include the Strong Interest Inventory, Myers-Briggs Type Indicator, and Holland’s Self-Directed Search (SDS).
    • Achievement and aptitude tests   measure how much a person knows or has learned; or predicts the capacity a person may have for certain topics.  Such tests include the Wide Range Achievement Test-III (WRAT-III) and Wechsler Individual Achievement Test-III (WIAS-III)
    • Other specific clinical tests may be indicated for specific problem areas such levels of anxiety, depression, or disordered behavior.
    • There are specific assessment/testing  protocols for children with learning disabilities, developmental disabilities, prenatal exposure to drugs or alcohol, other

When to refer:

  • When a client is not progressing in treatment; when a mental health provider (therapist or psychiatrist) has identified the need for testing to obtain a differential diagnosis;  usually based on a concern about underlying cognitive, personality, or other concerns creating a barrier to progress
A Sex Offender Risk Evaluation is an assessment of the risk and needs associated with sexual re-offense.

Who Can Complete: A Psychologist or Mental Health Practitioner with specialized training in assessment of sexual offense risk, including the use of empirically validated assessment instruments.

What this evaluation should include:

  • Clinical interview with the offender
  • Review and verification of collateral information (including police reports and treatment documents)
  • Application of standardized and validated tools to summarize an offender’s risk level
  • Use of at least one empirically validated instrument to estimate risk of sexual re-offending
  • Clinical formulation
  • Future treatment recommendations

When to refer:

  • When an individual is legally charged with or convicted of a sexual-related offense (e.g. sexual assault) and there is a demand to estimate the risk for re-offense and assess specific needs.

Summary: A Sex Offender Risk Evaluation is an assessment of the risk and needs associated with sexual re-offense.

A substance abuse evaluation is a clinical interview which allows a clinician to assess your struggles with substance use and provide you with future treatment recommendations. It is recommended for a substance abuse evaluation to also screen for possible mental health or medical concerns which could be contributing to your substance use.

Who Can Complete: Typically completed by a Licensed Alcohol and Drug Counselor (LADC) or a Licensed Mental Health Practitioner (LMHP).

What this evaluation should include:

  • Presenting Problems
  • Demographics
  • Medical History
  • Social/Work/School/Military history and functioning
  • Detailed substance use history (when it started, how it progressed and current status)
  • Legal history
  • Family and social history, including past and current exposure to violence/trauma
  • History and current mental health concerns
  • Past Treatment History
  • May include rating on ASAM criteria (American Society on Addiction Medicine)
  • Collateral information from referring party, family members, and other providers is ESSENTIAL to a good evaluation
  • Diagnosis
  • Clinical formulation (the professional’s insight into your past and current strategies)
  • Future treatment recommendations

​Tips for your first visit:

  • So that you don’t forget, you may want to write down a list of symptoms you are struggling with.
  • If you are currently on prescription medication, it may be helpful to provide a list to the clinician.
  • Bring along any medical or mental health records you feel would be helpful.
  • If you are anxious, it may help to ask a close friend or family member to come be a support for you.

When to refer:

  • When the primary reason for assistance is a substance related difficulty.

Summary: A substance abuse evaluation is a clinical interview which allows a clinician to assess your struggles with substance use and provide you with future treatment recommendations.

Nebraska Mental Health.com offers a general definition of common evaluations, however encourages individuals to check with their insurance carrier regarding specific evaluation requirements as they may differ by carrier.