Dean Hope Center
For Educational Psychological Services
Teachers College, Columbia University
Box 91, 525 West 120th. Street, New York, N.Y. 10027-6696
Tel. (212) 678-3262 Fax. (212) 678-8105
Dinelia Rosa, Ph. D., Director
Adult Quarterly Report
Client’s name: ______Date completed: ______
Sex: _____ Student: ______
Date of Birth: ______Age: ______
Dates covered by this Quarterly: ______
Description of client:
Describe the self-presentation of client during interview: age, sex, appearance, speech, grooming, attitude in relating to you, and ethnicity. Describe any changes from presentation during intake.
Chief complaint: (In client’s own words)
Describe briefly original complaint and provide an update including a brief history of presenting problem at the time. Using the client’s own words (in quotes) briefly state if clientperceives changes from original complaint.
Changes and updates (including significant changes relevant to presenting problem):
Presenting problems and stressors
Current environment
Alcohol and substance abuse
Developmental and social history
Gestation, infancy, childhood, adolescence, and adulthood
Psychosexual history
Educational/Vocational history
Social history
Criminal/Legal history
Family history
Family composition and significant history
Family psychiatric and medical history
Medical history
Multicultural evaluation
Language
Migration history, if applicable:
Cultural and racial identity
Spiritual/Religious history
Acculturation
Course of service:
Summarize the issues that have been a focus of the service provided in the preceding quarter. Include new problems that the client identifies as well as those identified by you and presented to the client. Incorporate some of the new findings and updates from history.
Write a succinct narrative summary of the course of service provision in the last quarter. Describe significant phases and milestones in the process. State the changes that have occurred in the client and client’s life, and note significant areas where there has been little or no change. State if there were changes in treatment modality and why.
Mental Status Examination: Provide an update from original MSE.
Appearance and behavior
Speech
Mood and affect
Thought process
Thought content
Sensorium and cognitive functioning examination:
Memory
Judgment
Insight
Summary impression:
Describe new insights and understandings that you have gained in this quarter based on new information obtained. Any new information used in the summary impression must be based on previous documentation evidenced throughout this report. Indicate any significant changes in cultural and clinical formulation. Also, if original diagnosis is changed, state here the rationale for the change.
Diagnosis:
Original DSM-V Diagnosis:
DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.”
Main Diagnosis: _____.______
Secondary Diagnosis (If applicable):_____.______
Personality Disorder: (If applicable): _____.______
In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that might be contributing to the diagnoses described above (Old Axis IV).
Updated DSM-V Diagnosis:
DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.”
Main Diagnosis: _____.______
Secondary Diagnosis (If applicable):_____.______
Personality Disorder: (If applicable): _____.______
In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that might be contributing to the diagnoses described above (Old Axis IV).
Service plan:
If service plan is the same as the most recent one, simply state “service objectives remain the same for the quarter,” however, briefly summarize what those are. Any new objectives or additions to the service plan are to be written here as described in the Intake Report sample.
New needs and recommendations:
Describe new needs identified and recommendations to address them. Include the impact ofcultural issues in treatment needs and recommendations.
Please indicate:
Continue with current student: ____
Continue in CEPSwith _____ Doc. Student____ Masters Student
Refer to CEPS for other services: ______
Refer out of CEPS ______
Trainee’s name: ______Supervisor’s name: ______
Trainee’s signature: ______Supervisor’s signature: ______
Date: ______Date: ______