![]() Axis III(General medical conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, Injuries.Axis II(Personality disorders, mental retardation) Examples: Borderline personality disorder, antisocial personality disorder, avoidant personality disorder, mental retardation.Axis I(Clinical Disorders, other conditions that may be a focus of attention) Examples: Substance abuse, substance dependence, anxiety disorders, mood disorders, schizophrenia.Diagnostic Justification Summary Press ENTER for next slide.Recommendation for treatment must indicate the level of care.cursory family history of significant medical problems Press ENTER for next slide.HIV, STD, TB or Hepatitis exposure or contact.injuries or disorders affecting the central nervous system.past and current physical illnesses or conditions. ![]() Get an idea of current emotional functioning.Client’s willingness to engage in the treatment process.What treatment approaches have or have not worked.A progression of behavioral health problems over a period of time.Can shed light on whether the current problem is part of a single or recurrent episode.Are legal problems directly related to substance use? Press ENTER for next slide.show compliance with treatment recommendations Press ENTER for next slide.show client’s ability for assuming the role of a client.give insight into the client’s ability to get along with others and take direction.be useful in developing an effective treatment plan.Ability to delay gratification Press ENTER for next slide.Aspirations, goals, ability to gain from learning experiences.Rough estimate of the client’s level of intelligence.Familial expectations for the client Press ENTER for next slide.The quality of clients relationship to parents and or siblings.The number of siblings and their birth order.The occupation and education of patents.History of previous substance abuse treatment received Press ENTER for next slide.Previous overdose, withdrawal, or adverse drug or alcohol reactions.Use or recovering from alcohol or other drugs.Behavior related to obtaining substances.Why do you think you need treatment? Press ENTER for next slide.Parts of the Assessment Presenting Problem or Chief Complaint Alcohol and Other Drug Use History (use) Family and Social/Leisure History (activities) Educational/Employment History (training) Legal History Mental Health History (mental/emotional functioning) Medical History (HIV, STD, TB, HEP) Client Strengths and Limitations Recommendations Press ENTER for next slide. ![]()
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