A full clinical assessment usually occurs during a several hour interview with a therapist or counselor. During the interview (the session) the counselor will ask questions regarding key aspects of a person’s life history, including the reasons that it is believed a counselor is needed. It is possible that nothing is wrong, but a professional assessment may be needed to be certain. The time of assessment is generally consumed with a large number of questions and might include interviews of family, friends, and other persons of significance. Sometimes the interview occurs in the office setting, in the home, at work and/or at school.
Sometimes the professional will not only ask questions but utilize seemingly common items (purposeful and incorporated as assessment tools) to obtain information indirectly during the interview. Common items used as assessment tools might be obtained from the disciplines of art, music, and children’s activities—such as play. Markers, crayons, dry erase boards, sand, balloons, paper, building blocks, figurines, stuffed animals, etc. etc. can help understand dynamics that cannot always be verbally articulated in a traditional question/answer discussion. These assessment tools can help with not only assessing, but also in treating adults and children, individuals, couples, families, and groups. Why use sand, balloons, paper, building blocks or art, music and play in assessment processes?
The clinical assessment ultimately culminates in a written report, based upon a review of a person’s life history including past issues of significance as well as present circumstances. Often clinical assessments will include some review of future life events (such as dreams, hopes and desires) and some professionals (usually clinical social workers) include an assessment of strengths.
The written report is usually sub-divided into several areas: family of origin and place of birth, medical history, psychiatric history, presenting problems, prescribed medications, substance use, sexual behavior, spirituality, legal issues, social supports, and job/school issues. The report often includes a summary, recommendations for other assessment needs, rule outs to be considered, a diagnostic impression, and a treatment plan (if a diagnosis exists).
Not every professional who offers mental health counseling services will write a report following the clinical assessment, sometimes because the cost of such reports can be relatively high (ranging from $250 to $1,500 or more) and/or because clients will ask that such a report NOT be completed. Other professionals strongly encourage the written report and an accompanying treatment plan as a point of reference to support a diagnosis and provide a structured treatment plan. Sometimes there are legal reasons that a written report is generated as well, such as in the case of court ordered assessments, abuse cases, and/or in divorce proceedings.
For more information, please see the published “Assessment, Diagnosis and Treatment” article.