Clinical Assessment Questions
Choosing correct clinical assessment questions helps you conduct a competent clinical assessment.
Are clinical assessments ever complete? Yes and no. Yes, the clinician will finish any one assessment, but as changes are made by the client(s), so will changes be made in the assessing and diagnosing of the client or system. Assessment is best seen as a continual process.
However long an assessment takes, it must be started somewhere. Let’s start with the questions listed below:
- What is the presenting problem?
- What brings you here today?
- How long has this been a problem?
- Have you noticed times when the problem isn’t as bad?
- Has anything like this happened before?
- If so, how? How did you try to resolve this problem the last time?
- How often has this problem occurred?
- Who is involved or affected by this current problem/situation?
- What is your goal in coming to counseling?
- What would you like to get out of this appointment time?
- What changes would you like to see happen?
- What are some things in your current situation you would like to keep or stay the same?
- How will you know (what will you be thinking and doing differently)such that you won’t need to come back to a place like this anymore?
Other clinical assessment questions:
- Have you experienced any recent changes in eating, sleeping, mood or concentrating?
- Have you gained or lost any weight recently?
- What is your level of alcohol or drug use? See C/D Assessment.
- Have you had any thoughts currently, or in the past, of wanting to do anything to hurt yourself or someone else? See Safety Assessment.
- Has your current problem or difficulty been affecting your health?
- Has your current concern(s) affected your ability to perform your duties at work, school or home?
- Do you have important people in your life to talk to, or do you tend to keep your problems to yourself?
- Have you had any recent problems with the police?
- When was your last physical exam? Any concerns?
- Are you taking any medications?
- Have you had any recent hospitalizations?
- Do you have any history of physical or sexual abuse?
- Do you see or hear things others might not?
- Have you ever been in therapy before?
I hope you find these clinical assessment questions useful. Please know that if you are presented with a situation in which you are unsure what to do, or if you have any question of your client’s safety, then I would suggest you immediately seek consultation/supervision from a licensed mental health professional practicing within your field of study.
To find out information about substance abuse, stages of use, abstinence, recovery and relapse prevention, just to name a few you might want to click on Substance Abuse.
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