Conducting Clinical Assessments

The purpose of a conducting clinical assessments according to the medical model is to gather information enabling the clinician to determine a diagnosis. The diagnosis sets up a treatment plan which is expressed by treatment interventions. The results of the interventions are continually assessed as to whether or not client symptoms are reduced or relieved.

The clinical assessment usually entails both asking questions and making direct observations whereby the clinician gets information about the nature, duration and severity of the client’s problem(s).

A good assessment will cover the client’s internal thoughts and feelings, coping, relevant past history and supports. I also believe a competent assessment will include the client’s goal in seeking services.

Assessments can be competently completed in one hour, but sometimes this is not always done. The client may not be cooperative, may be overcome with shock, grief or trauma, or present with so many problems that it’s hard for the clinician to collect all the needed information within the hour. It is not uncommon for the clinician to need or use a few sessions to feel they have a handle on the nature of the client’s problems. This is even more true when seeing couples.

When seeing couples the clinician is aware of each individual goal, the method of problem solving the couple uses, the amount of self-responsibility each person takes towards creating the current problem(s) and the willingness of each person to create a new solution.

The clinician is responsible for managing the clinical hour. When people present for the first time, they usually have a story to tell. The clinician may have to interrupt or redirect the client, in order to stay focused and complete the assessment. Of course, managing the client(s) in this way is best done with respect and using manners. Transitional sentences can be used:

“I understand (clinician paraphrases what client had just said), and I wanted to get back to a few questions I have to ask you.”

“I can see that is important to you. As soon as I’m finished with a few more of my regular questions, I’d like to return to what you just mentioned.”

“Oh, yes, now that you mentioned your friends, that reminds me I’d like to ask you a few questions about your support system.”

The information presented regarding assessments is not intended to offer any type of legal advice or specific case consultation. The information is presented for a broad perspective on clinical assessments. I suggest you seek the consultation of a licensed mental health provider or your supervisor for any specific questions.

Click Assessment Questions to learn questions used in a general clinical assessment.

If a clinician determines more assessment is needed in chemical dependency, then click C/D Assessment or click Safety Assessment for a more detailed assessment in this area.

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