Serenity Programme TM

This form completed by: Designation: Date:

Client contact details
Forename(s)
Surname
Title / Ms. | Miss | Mrs. | Mr. | Dr. | Rev. | Other (please specify)
Birth name (if different)
Preferred choice of name
Preferred language
Date of birth
Sex
National identity / English Scottish Welsh Irish British Other
Ethnic origin / (White) British any other White background (specify)
(Mixed) White & Black Caribbean White Black African
White & Asian any other mixed background
(Asian or Asian British) Indian Pakistani Bangladeshi any other Asian background
(Black or Black British) Caribbean African any other Black background
(Chinese or other) Chinese any other (specify)
Religion
Occupation / Is client currently working? Yes No
If employed, time unavailable for work due to symptoms in last 6 months / N/A
Next of kin contact details
Dependents
Address
Unique identifier
CPA level / None Standard Enhanced
Serenity pass code
Email / OK to send email? Yes No
Evening ‘phone / OK to leave message? Yes No
Daytime ‘phone / OK to leave message? Yes No
Mobile ‘phone / OK to leave message? Yes No
Contact preferences / Preferred method and time of contact
Referrer contact details
Name
Address
Telephone
Feedback arrangements
Continued involvement? / Yes No
General Practitioner contact details
Name
Address
Telephone
Care coordinator | Key worker contact details
Name
Address
Telephone
Allocated Serenity Programme helper contact details
Name
Address
Telephone
Primary method of contact with helper (please tick one)
( / . / JJ / Â / : / 9 / 7 / 4 / ´
‘Phone / Post / Face-to-face / Group clinic / Email / Video / Chat or IM / Fax / Other
Agreed frequency of contact with helper (please tick one)
/ / / / / / ´
Weekly / Fortnightly / 3-weekly / Monthly / 5-weekly / 6-weekly / 8-weekly / Other
Access to the Internet (please tick one)
Home broadband / Home dial-up / Library / Other hi-speed / Other lo-speed / None
Client’s use of computers? (please tick one)
Never / Occasionally / Often / Most days / Every day
Current medication
Medication / Dose / Morning / Afternoon / Evening / As required / Other
Physical health and allergies
Include any known allergies and current or ongoing physical health problems or any identified special needs.
If ‘No known allergies’, please tick this box
Non-prescribed drugs, stimulants etc
Include caffeinated and stimulant drinks, tea, coffee, smoking, non-prescribed drugs and alcohol use - please record quantity and frequency
Family background
Include birth order, brothers / sisters, close and extended family overview, history of mental health problems in family (please specify) – ask – ‘How would you describe your family / childhood?’
Clients social support network
Identify those people who will support the client in their recovery
Clients perception of problem / diagnosis and related information
Use / involvement of other agencies / supports
Please record agency, nature of support and frequency of contact
Current stressors
Please include: Health Health | Financial Financial | Relationship Relationship | Legal Legal | Loss of attachment Loss | Employment Employment | Sexual Sexual | Accommodation Accomodation | Exploitation by others Exploitation | Sleep Sleep | Anticipated future stressors Future | Other (please specify) Other
Sleep
Describe sleep pattern
Difficulty getting to sleep , frequent waking during night , early waking , sleep disturbed by dreams , quality of dreams, number of hours sleep each night, desired or usual number of hours each night
Precipitating events
Did the problem seem to start after a specific event of situation?
Homework
Part of self-help programmes involve time spent carrying out homework tasks. Would the client be able to do this? Yes No
Hobbies and pastimes
What does the client enjoy doing? How much time have they spent doing this over the last month? When did the client last take a holiday?
Risk assessment
Risk from others (violence, abuse, exploitation) / No Unknown Yes (please specify)
Risk to self (intentional self-harm) / No Unknown Yes (please specify)
Risk to others (aggression, violence, impulsivity) / No Unknown Yes (please specify)
Risk of neglect (unintentional self-harm) / No Unknown Yes (please specify)
Risk to children (neglect, abuse) / No Unknown Yes (please specify)
Risks due to physical impairment / frailty / No Unknown Yes (please specify)
Risk due to memory / cognitive impairment / No Unknown Yes (please specify)
Challenges to services (inappropriate demands) / No Unknown Yes (please specify)
Clients desired change
If the client overcomes this problem, what might they look forward to being able to do that they can’t do now? (Or what are they looking forward to not having to do, that they do now?)
Previous successful interventions
What treatments / interventions, if any, have worked in the past? (these may be formal treatments or things the client has done for themselves)
Global assessment of functioning at assessment
91 - 100 / Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
81 - 90 / Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.
71 - 80 / If symptoms are present they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning.
61 - 70 / Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.
51 - 60 / Moderate symptoms OR moderate difficulty in social, occupational, or school functioning.
41 - 50 / Serious symptoms OR any serious impairment in social, occupational, or school functioning.
31 - 40 / Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.
21 - 30 / Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas.
11 - 20 / Some danger of hurting self or others OR occasionally fails to maintain minimal person hygiene OR gross impairment in communication.
01 - 10 / Persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
Interview guide
What do you see as the main problem that you would like help with?
Behavioural deficits: Are there any things you avoid, or do less of, because of the problem; or to make you feel better or cope with the problem?
Behavioural excesses: Are there any things you do more of because of the problem; or to make yourself feel better or cope with the problem? Are there things that your family or friends do for you to help you with the problem or make you feel better?
Agoraphobia: Do you avoid public places from which a quick escape may be difficult (e.g. public transport, shops / town centres, queues, cinema, unfamiliar buildings, being far from home)?
Panic: In the last 2 weeks have you experienced any sudden or “out of the blue” attacks of anxiety?
(a) What physical symptoms did you experience? How long did they last for? / Yes No
Social phobia: During the last few weeks, have you avoided any social situations for fear that attention might be drawn to you, or that people might be judging or criticizing you? / Yes No
Specific phobia: Check for small enclosed spaces, vomit, blood / injury / injections (Hospitals / dentists), heights, flying, thunder, animals / insects etc.
OCD - obsessions: Check for any unwanted thoughts about bad things, things going wrong, doubts, etc.
OCD – compulsions / rituals: (overt actions or covert psychological rituals). Check for any things the person does to counteract unwanted thoughts or to prevent / control anxiety, e.g. repetitive checking, counting, cleaning, putting things in order, hoarding, repeating something in their head etc.
Feared consequences: What do you think is the worst thing that could happen in this situation?
PTSD: Have you ever experienced, or witnessed, an unusually upsetting event, and suffered any after-effects of this event?
If YES:
·  How long ago the event occurred - how long after the event symptoms started.
·  Re-experiencing phenomena causing distress: no need to for details – use peripheral questioning e.g. whether mental images, nightmares or thoughts, how often occur, can the person get rid of them and how, what emotions do they go through when experiencing these (e.g. fear, sadness, anger)
·  Difficulty recalling aspects of the event
·  Hyper-vigilant, feeling ‘on edge’, checking, etc.
·  Avoiding things / places / people that remind the person of the event / Yes No
Health anxiety / somatisation: Are there any physical problems that you worry about? (check whether these are consistent and long-term, or varied and intermittent)
If YES:
·  Do you check yourself or go to the doctor’s frequently because you worry?
·  Do you find it hard to stop worrying about your physical problems?
·  Do you think there is something seriously wrong with your health that other people, or your doctor, have missed? / Yes No
GAD: During the past 6 months, have you been feeling worried, tense or anxious about everyday events and problems? (And the worry was unrelated to phobia, OCD, panic attacks, having a serious illness, having multiple physical complaints).
If YES:
·  What sort of everyday things do you worry about? (e.g. children’s health, safety of home and family, school or work performance)
·  How easy is it for you to control your worry? Have you been worrying much more than other people in your situation would do? Are you a worrier?
·  Does worry interfere with your everyday activities? In what way? (work, home, private leisure, relationships)
·  When you feel anxious and worried what physical and mental symptoms do you get?
·  Is there any seasonal / cyclical / menstrual variation in symptoms or intensity / Yes No
Restlessness / feeling ‘on edge’
Fatigue
Concentration problems
Muscle tension
Sleep disturbance
Irritability
Palpitations
Sweating
Trembling
Dry mouth
Difficulty breathing
Feeling of choking
Chest pain
Abdominal distress
Feeling light-headed or dizzy
Derealisation / depersonalisation
Fear of losing control
Fear of dying
Hot / cold flushes
Numbness / tingling sensations
Difficulty swallowing
Feeling ‘jumpy’ or easily startled
Suicidal ideation or behaviour / thoughts of death? / Yes No
Plans made
Articulates intent with conviction
Opportunity
Lack of interpersonal support
Inadequate coping strategies
Sense of hopelessness
Previous attempts
Depression
Depressed mood for most of the time over preceding 2 weeks? / Yes No
Loss of interest or pleasure? / Yes No
Decreased energy levels / increased fatigability? / Yes No

Secondary symptoms

Confidence / self-esteem lowered? / Yes No
Guilt / self-reproach? / Yes No
Concentration / memory / indecisiveness? / Yes No
Psychomotor activity (agitation or retardation)? / Yes No
Sleep disturbance (early waking & mood worse in morning)? / Yes No
Changes in appetite or weight (decrease or increase)? / Yes No
Adapted from Gega, L., Kenwright, M., Mataix-Cols, D., Cameron, R. Marks, I. Screening people with anxiety / depression for suitability for guided self-help. From Cognitive Behaviour Therapy, 34:1, March 2005, pp. 16-21(6).
Risks and planned contingencies
Include any risk of harm to self, others, property, specific vulnerabilities, possibility of escalation or deterioration
Future plans and / or any actions required
Include how referrer will be made aware of progress and / or risks
Additional questions
Is there any other information the client perceives as relevant – ‘Are there any other questions you hoped I would ask you?’ Is there anything I should know which we haven’t yet mentioned?’
Key issues identified at assessment
Are there any key issues or early actions required from the initial assessment?
DASS Scoring Guide / Depression / Anxiety / Stress
Normal / 0 – 9 / 0 - 7 / 0 – 14
Mild / 10 – 13 / 8 – 9 / 15 – 18
Moderate / 14 – 20 / 10 – 14 / 19 – 25
Severe / 21 – 27 / 15 – 19 / 26 – 33
Extremely Severe / 28+ / 20+ / 34 +
Baseline assessment – Date of contact Duration of contact
HADS DASS PHQ-9 CORE HAM-A HAM-D BAI BDI Other
(if ‘other’, please specify measure used)
Baseline scores:
HADS-A HADS-D (0-7 = normal, 8-10 = mild, 11-14 = moderate, 15-21 = severe)
PHQ-9 (0-4 = normal, 5-9 = mild, 10-14 = moderate, 15-19 = moderately severe, 20-27 = severe)
Face-to-face assessment telephone assessment
Signed
Section / contact 1 notes – Date of contact Duration of contact
Signed
Section / contact 2 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 3 notes – Date of contact Duration of contact
Please record DASS score. Please also record client’s goals on later pages.
D = A = S =
Signed
Section / contact 4 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 5 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 6 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 7 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 8 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed
Section / contact 9 notes – Date of contact Duration of contact
Please record DASS score:
D = A = S =
Signed

1. Completed on (date):

2. Clients overall SMART goal: