Evaluation Face Sheet

Evaluation Face Sheet

Case File #:______Case Source: Treatment Center Private Practice Date Form Received: ______

Referred by______

Year of Birth: ______Sex: male female

Race: Religion: Sexual Preference:

white protestant heterosexual

african-american catholic homosexual

asian jewish bisexual

hispanic muslim

other none

other

Relationship Status: Lives with: Number of Children: ______

single alone Birth years or Ages of Children: ______

married spouse Lives with Children:

living with partner significant other yes no

divorced parents

separated roommates

widowed

Highest degree (circle): HS dip / BA / MA / MFA / PhD / MD / JD / MBA

Occupation: ______

Annual Income:______

Current Psychotropic Medication and dosage: (Rx and OTC)

medication name / dosage / date began / reason for starting / response

Previous Psychotropic Medication Treatment: (Rx and OTC)

medication name / dosage / date began / reason for starting / duration (months) / response

Current Psychotherapeutic Treatment (ongoing at present)

modality* / frequency/wk / date began / reason for starting / therapist name / response

*modality of Rx = Supportive-expressive, dynamic, IPT, CBT, DBT, TFP, analysis, couples, group, other

Previous Psychotherapeutic Treatment

modality* / frequency/wk / date began / reason for starting / duration (months) / therapist name / response

*modality of Rx = Supportive-expressive, dynamic, IPT, CBT, DBT, TFP, analysis, couples, group, other

Current Medical Problems:

Current Non-Psychotropic Medication and dosage: (Rx and OTC)

medication name / dosage / date began / reason for starting / response

Past Medical History (with dates)

Illnesses:

Hospitalizations:

Operations:

Significant history of (check all that apply):

headache irritable bowel syndrome

eczema menstrual irregularity

Alcohol Use: yes no (amount per day) ______

Smoker: yes no (packs per day)______

Caffeine Intake: (per day)______

Current Drug Use: yes/no

if yes: type quantity/frequency when began

Past Drug Use: yes/no

if yes: type quantity/frequency when used (date)

Allergies:

Allergies to Medication:

Early traumatic history: yes no

physical abuse

sexual abuse

early object loss (of parent, before age 9)

primary caretaker with psychotic illness, substance abuse

Lifetime history of suicide attempts/gestures: yes no

Lifetime history of self-mutilation (including cutting, burning, hair pulling): yes no

Sexual symptoms: yes no unknown

inhibition

perversion

Patient=s capacity to reflect on own and others= inner states and motivations (please rate):

0 no capacity

4 psychologically minded, able to reflect

DSM-IV diagnosis:

Current Axis I:

Past Axis I: (no longer active)

Axis II

Axis III:

Axis IV: none mild moderate severe

Axis V: (please note number from 10-90 as per DSM IV): ______

Psychoanalytic character diagnosis (descriptive diagnosis):

Select from the list below:

a. Most prominent character style

(Select one only)

antisocial

avoidant

borderline

dependent

depressive

hysterical

infantile/hysteroid

masochistic

narcissistic

obsessional

paranoid

passive aggressive

sadomasochistic

schizoid

schizotypal

b. Prominent additional features

(Mark “1”, “2”, or “3” in descending order of importance)

___ antisocial

___ avoidant

___ borderline

___ dependent

___ depressive

___ hysterical

___ infantile/hysteroid

___ masochistic

___ narcissistic

___ obsessional

___ paranoid

___ passive aggressive

___ sadomasochistic

___ schizoid

___ schizotypal

Narcissistic Pathology:

If you checked narcissistic in a or b above, which most accurately describes this patient (select one only)

Narcissistic personality

Prominent narcissistic defenses in the absence of a narcissistic personality

Predominant level of structural organization (structural diagnosis):

(Select one only)

Neurotic

Borderline

Psychotic

If Neurotic, Borderline Features are Present Absent

Key to Level of Psychological Organization

Psychotic

· Reality testing is impaired or easily lost under stress.

· Poorly consolidated sense of self (identity diffusion)

· Object representations are poorly integrated (Apart objects@

· Relies primarily on combination of psychotic and primitive defenses, although higher level defenses may also be present.

Borderline

· Reality testing is generally intact but may be transiently lost under stress or in regressive settings

(e.g., transference psychosis)

· Poorly consolidated sense of self (identity diffusion) or more stable, but pathological sense of self

(pathological grandiose self)

· Object representations are poorly integrated (part objects)

· Relies primarily on primitive defenses, although higher level defenses may also be present

Neurotic

· Reality testing is intact

· Well consolidated sense of self (consolidated identity/ No identity diffusion)

· Object representations are well integrated (whole objects)

· Relies primarily on higher level defenses, although primitive defenses may also be present

If Treatment Center Eval:

Date Eval Began: ______Date Eval Ended: ______Number of Evaluation Sessions: ______

If Private Practice Eval:

How long did you see patient prior to psychoanalysis? ______(months) frequency?______

if patient seen for less than 2 months, total # of sessions seen______

Was patient referred to you specifically for analysis: yes no

Outcome of Evaluation

I am ____recommending ____not recommending analysis for this patient.

If not recommending, the following alternative referral(s) were given to the patient:

Evaluator: ______

Evaluation Supervisor: ______Admitting Psychoanalyst: ______