Gyandeep Rohtak counselling history and evaluation format.
Gyandeep Guidance Counselling and Rehabilitation Services was established on 16th of October 2017.
https://gyandeeprtk.in/
We provide Counselling in various domains
Education Counselling
Career Counselling
Vocational Counselling
Anxiety or Fears
Stress
Phobia
Depression
Addictions
Domestic Abuse or Violence
Substance Abuse
Mental Health
Sports Counselling
Mindfulness-Based Cognitive Therapy
Family Therapy
Spirituality
Individual Psychotherapy
Relationship Issues
Couple Counselling
Marriage Counselling
Pre-Marital Counselling
Adolescent Psychotherapy/ Teen Counselling
Parental Guidance
Rehabilitation
Relaxation and Meditation Therapy
Individual Counselling
Queer Wellbeing & Mental Health Counselling
Family Therapy
Adolescent/ Teenage Wellbeing & Mental Health Counselling
Counselling for sexual issues
Grief Counselling Rehabilitation Counselling
Art & Movement-Based Therapy
Crisis & Trauma Intervention
De-addiction Counselling
Psycho-education: Keeping you informed about the diagnosis you may have, equipping you with the knowledge like symptoms and what you can do.
More than Just Lines on a Map: Best Practices for U.S Bike Routes
Gyandeep rtk counselling history and evaluation format
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GYANDEEP GUIDANCE COUNSELLING AND REHABILITATION SERVICES
ROHTAK (HARYANA)
COUNSELLING HISTORY AND EVALUATION
Socio Demographic Data
1. Name -
2. Father's/ Spouse's Name -
3. Gender/Sex (M/F/O)
4. Age (DOB) -
5. Marital status -
6. Education -
7. Occupation -
8. Monthly income -
9. Religion -
10. Family Type -
11. Locality (urban/rural) and Distance from the centre. -:
12. Information Gathered From.
Name Relationship With Ct. Known to Ct. since
(yrs).
Reliability of the information.
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13. Present and permanent addressee -
14. Contact Numbers – i) ii) iii)
iv) v)
Date : / / Case writing done by
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CHIEF COMPLAINTS (in chronological order with duration)
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HISTORY OF PRESENT ILLNESS (duration, Mode of onset, course and precipitating factors)
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HISTORY OF PAST ILLLNESS
A) PSYCHIATRIC HISTORY ( duration, number of episode, similarity with present illness)
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B) MEDICAL HISTORY
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TREATMENT HISTORY
A. PRESENT
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B. PAST
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FAMILY HISTORY
A. Family history (genogram)
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B. Family history of mental illness or drug addiction
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C. Family interpersonal relationship:
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PERSONAL HISTORY
1. Birth and development
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2. Education
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3. Occupation
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4. Marital and sexual.
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5. Habits & Addiction
A. Choice of Substance -:
B. Total Duration of use -:
C. Duration of Regular use -:
D. Last Intake of Drug (day/time and quantity of thedrug).
E. Mode of Intake -: Oral / Smoke / Inhale / Inject / Other’s.
6. Pre-morbid personality.
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7. Emotional Problem. Specify if any?
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8. H/o Homicide/Suicide Attempts
If yes, specify the number of attempt and method.
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MENTAL STATUS EXAMINATION (MSE)
GENERAL APPEARANCE AND BEHAVIOUR
Appearance Looking one’s age / Older / Younger
Level of grooming Normal / Shabbily Dressed / Over Dressed / Idiosyneratically Dressed.
Level of cleanliness Adequate / Inadequate / Overtly clean
Level of consciousness Fully conscious and alter / Drowsy / Stuporose / Comatose.
Mode of entry Came willingly / Persuaded / Brought using physical force.
Cooperativeness Normal / More than so / Less than so /
Eye to eye contact Maintained / Difficult / Not maintained.
Empathy Easy / Difficult / Sustained / Unclear.
Rapport Spontaneous / Difficult / Not established.
Quality of rapport Good / Poor
Gesturing Normal / Exaggerated / Odd
Posturing Normal Posture / Catatonic Posture
Other Movements Mannerisms / Stereotypes / Tremors / EPS / AIMS / Perseveration
Other Catatonic Phenomenon Automatic Obedience / Negativism / Excessive Cooperation / Waxy
Flexibility / Echoproxia / Echolalia.
PSYCHOMOTOR ACTIVITY
Psychomotor Activity Normal / Increased Restlessness, Agitation, Excitement / Decreased.
SPEECH
Initiation Spontaneous / Speaks When Spoken To / Minimal / Mute.
Reaction Time Normal / Delayed / Shortened / Difficult to Assess.
Speed Normal / Slow / Rapid / Not Clear.
Output Normal / Increased / Decreased / Variable.
Pressure of Speech Present / Absent.
Volume Normal / Increased / Decreased /
Tone Normal Variation / Monotonous
Manner Normal / Highly Formal / Inappropriately Familiar
Relevance Fully Relevant / Some Time Off Target / Irrelevant
Coherence Fully Coherent / Over Elaborate, Digressive / Some Loosing Of
Associations / Incoherent.
Other Rhyming / Punning / Echolalia / Perseveration / Neologism.
Sample Of Speech In Response To
Open Ended Questions.
THOUGHT
Form Adequate / Woolly Thinking / Loosening Of Association / Formal
Thought Disorder (FTD).
Stream Normal / Circumstantial / Tangential
Provide Sample Of Speech For
Example Of Disorder Of Tempo
And Form
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POSSESION
A. OBSESSIVE COMPULSIVE PHENOMENON
Major Content / Interference / Repetitiveness / Distress / Recognition Of Inappropriateness OR Irrationality
OBSESSION -: Thought / Doubt / Impulse / Image / Rumination.
COMPULSION -: Yielding / Controlling / Cognitive Compulsion.
Provide Examples -:
B. THOUGHT ALIENATION PHENOMENON
Thought Insertion / Withdrawal / Thought Broadcast / Thought Commentary
Provide Examples -:
Thought Contents -: Idea / Over Valued Idea / Delusion / Somatic Preoccupation / Suicidal Ideation /
Depressive Cognition.
Provide Examples -:
Worthlessness Nihilistic Reference Fantastic Delusion Primary / Secondary
Helplessness Hypocondrical Control Delusional Memory Delusion.
Hopelessness Death Wish Influence Delusional
Guilt Suicidal Ideas Persecution Confabulation
Ill Health
Poverty
Grandiose Ability
and Identity
Bodily Change
Religious
Bizarre
(single / multiple / simple
/ elaborate / systematized /
non-systematize / mood
congruent / incongruent /
degree of distress /
interference with work /
reaction to phenomenon )
Provide Examples -:
MOOD
Subjective Predominant Mood State / Other Major Moods / Range / Reactivity / Quality Of Mood /
Communicability / Labiality m/ Appropriateness / Congruence / Incongruence.
Emotional Expression -: Normal / Blunted / Flattened.
Objective
Description -:
9. 9
PERCEPTION
HALLUCINATION PSEUDO
HALLUCINATION
ILLUSUON. Single / Multiple
One Modality /Many Modality
Elementary / Partially
Formed / Fully Formed
Occasionally / Continues
Mood Congruent / Mood Incongruent
Auditory Depersonalization
Visual Derealization
Olfactory
Gustatory
Tactile
Somatic
(Somatic Passivity)
Description -:
COGNITIVE FUNCTION
Attention Normally Aroused / Aroused with difficulty.
Digit Forward :-: Digit Backward
Concentration Normally Sustained / Sustained With Difficulty
100 – 7 =
40 – 3 =
20 – 1 =
Name of Month (backward)
Name Of Week Days (backward)
Orientation
Time -: Approximate Time / Day-Night / Date / Day / Month / Year.
Place -: Kind Of Place / Area / City
Person -: Self / Close Associates / Other Staf.
Memory Immediate
Recent
Verbal Recall. After 5 min After 10 min
3 unrelated object …………… …………….
5 unrelated object …………… …………….
Visual Recall
3 or 5 unrelated object …………… ……………
Remote -: Personal Events -: ………………………………..
Impersonal Events -: ………………………………..
Illness Related Events -: ………………………………..
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INTELLIGENCE
Comprehension Simple Commands / Complex Commands
Vocabulary Common Object / Uncommon Object / Part Of Object
General Fund Of Information ie. 1. Name of the president of India. 2. Current affairs. 3. Name of the
common state capital. ect.
Arithmetic Ability Mental Arithmetic / Written Sums
Abstraction Normal / Concrete / Personalized / Bizarre
Interpretation of proverb.
Similarities between paired Object
Dissimilarities Between Paired
Object
JUDGMENT
Intact / Impaired
Personal Sense Of Personal Capability or Worth and Planning Of Future.
Social Sense Of What Is Social and Culturally Acceptable.
Test Perception Of Human Behaviour In Imaginary Situation.
Fir Test
Letter Test
INSIGHT
Awareness Of Abnormal Behaviour
/ Experience
Yes / May Be / No
Attribution To Physical Cause Yes / May Be / No
Recognition Of Personal
Responsibility.
Yes / May Be / No
Willingness To Take Treatment Yes / May Be / No
GRADE Grade I No Insight
Grade II
Grade III
Grade IV
Grade V
Grade VI Full Insight
