(If described behaviours or examples fit into multiple criteria, only include in the most relevant/salient criteria. Do not list the same example in multiple places. Provide direct quotes where salient information is provided.)
Reason for Assessment:
[Describe the reported reason for referral. Any relevant thoughts or notes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as concise paragraph.)
Mental Status Exam:
[Describe the client's appearance] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe the client's behaviour] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail speech patterns] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe the client's mood] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe the client's affect] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail any hallucinations or dissociations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe the client's thought process] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail the form of thoughts, including any disorderly thoughts] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail orientation to person, time and place] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe memory function] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail concentration levels] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe attention span] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Detail judgement capabilities] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe the patient's insight into their condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Previous/Current Engagement with Services:
[Describe client's previous engagement with psychologists] (Only include if explicitly mentioned in transcript or context, else state "Client reported no previous engagement with psychologist.")
[Describe client's engagement with allied health professionals, including speech pathology, occupational therapy] (Only include if explicitly mentioned in transcript or context, else state "Client reported no historical and/or current engagement with allied health services.")
[Describe client's engagement with a paediatrician] (Only include if explicitly mentioned in transcript or context, else state "Client reported no historical and/or current engagement with a paediatrician.")
[Describe client's engagement with a psychiatrist] (Only include if explicitly mentioned in transcript or context, else state "Client reported no historical and/or current engagement with a psychiatrist.")
Diagnostic Information:
[State whether the client has received a diagnosis] (Only include if explicitly mentioned in transcript or context, else state "Client reported no diagnoses.")
Current Medications:
[List type, frequency, and daily dose of current medications in detail] (Only include if explicitly mentioned in transcript or context, else state "Client reported no prescribed medication.")
Presenting Concerns:
[Describe client's presenting concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include direct quotes and write in full sentences.)
Impact on Functioning:
Sleep: [Detail sleep patterns] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Social: [Describe social interactions and the client's support network] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Exercise/Physical Activity: [Describe impact on exercise or physical activity] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Eating Regime/Appetite: [Describe impact on eating habits and appetite] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Energy Levels: [Describe impact on energy levels] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Social Functioning: [Describe how functional skills or distress is caused by symptoms] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns.")
Medical History:
[State whether client has had a vision assessment. Describe outcome.] (Only include if explicitly mentioned in transcript or context, else state "Client reported no concerns regarding vision.")
[State whether client has had a hearing assessment. Describe outcome.] (Only include if explicitly mentioned in transcript or context, else state "Client reported no concerns regarding hearing.")
[Describe any serious medical conditions, including date of onset, treatment, and impact on functioning] (Only include if explicitly mentioned in transcript or context, else state "Client reported no serious medical conditions.")
Family History:
[Describe family psychiatric and medical history] (Only include if explicitly mentioned in transcript or context, else state "Client reported no family history of mental health conditions.")
Trauma History:
[Describe any traumatic events experienced, including age and context] (Only include if explicitly mentioned in transcript or context, else state "Client reports no traumatic events.")
Pregnancy and Birth:
[Describe pregnancy and birth history including complications or hospital admissions] (Only include if explicitly mentioned in transcript or context, else state "No complications reported during pregnancy or birth.")
Early Development:
[Describe developmental milestones from newborn through preschool] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns regarding developmental milestones.")
[Describe sleep patterns as newborn, infant, preschooler] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns regarding client's sleep pattern.")
[Describe eating habits] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns regarding client's eating habits.")
[Describe toilet training] (Only include if explicitly mentioned in transcript or context, else state "No reported concerns regarding client's toileting skills.")
Home Environment:
[Describe home environment, including household members, family relationships and dynamics] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
Home Functioning: [Describe functional skills or distress in the home] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
School Environment:
Current school: [State client's current school]
Year: [State client’s current school year]
[Describe preschool experience] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe primary school experience] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Describe high school experience] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Academic Functioning: [Describe functional impairments at school] (Only include if explicitly mentioned in transcript or context, else state "Presenting symptoms are not reported to impact academic functioning.")
[Describe social skills, friendships, challenges] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Occupation:
Current work place: [State where client currently works]
[Describe current work environment and challenges] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Occupational Functioning: [Describe functional impairments at work] (Only include if explicitly mentioned in transcript or context, else state "Presenting symptoms are not reported to impact occupational functioning.")
Assessment Plan:
Client's pre-assessment will be discussed at the Lighthouse Psychology Practice's assessment meeting.
[Describe assessment goals, proposed questionnaires, and assessments] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
