Therapist Input Form
If you are receiving this form it is because the patient has signed a 2 way release authorizing us to reach out for your input. If you would like a copy of this, please email support@claritypsychologicaltesting.com. Thank you very much for taking the time to fill this out for your patient. Therapists input/lens are crucial in understanding elements of the patient that aren't always picked up in our norm based testing. Your insights are thoroughly read and used to develop this patient's report and further enhance your treatment planning.
Provider Name, Credentials, and Facility
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Phone number
Date
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Month
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Day
Year
Date
Email or Fax you would like report sent to:
Preferred Method of contact
email
fax
phone
text
Patient Name
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Approximately how long have you been working with this patient?
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How motivated does this patient seem to participate in therapy?
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5
How motivated does this patient seem to participate in therapy with 5 being the best?
Worst
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Best
5
1 is Worst, 5 is Best
What are the most salient symptoms, challenges, or issues you are observing in the course of your work with them? (anger, social impairment, lack of insight, trauma, depression, disordered eating, family issues, self-esteem issues, disorganization, too much social media, isolation, suicidal ideation, self-harm, borderline personality traits, antisocial traits, no sense of purpose, inability to take ownership, academic issues, etc.)
Social Functioning ( do you hear them talk about the same friends regularly? are they able to adequately initiate and maintain friendships? do you see any reality distortions? any issues with social anxiety? social skill impairment?) Do they seem to have a healthy desire to have friends, no desire, or avoidance of relationships?
Family Functioning: Is there anything relevant to their family that might help understand them better? raised by a single parent? parents over bearing? raised in a different culture? are they close and connected? have they never had a romantic relationship? are they an only child? do they seem to be the caretaker in their family?
ADHD Concerns: Are you noticing anything that might be indicative of ADHD like a long term history of school related issues dating back to childhood? disorganized thought processes? tangentiality? are you frequently having to redirect their train of thought or remind them of the original question? do they often forget appts despite consequences of having to pay fees? do they seem to zone out at times? do they find it difficult to work towards their goals? are they impulsive? do they procrastinate? do you notice fidgeting?
Substance abuse concerns? any concerns around addiction either with them or their family? recreational drugs? thc? opiates? alcohol? stimulants? laxatives? diuretics?
How would you rate this patient's ability to take ownership for their role in their challenges?
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How would you rate this patient's motivation for growth and change?
Worst
1
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Best
5
1 is Worst, 5 is Best
Severity of symptoms: Are there any concerns that this patient might be experiencing psychosis? paranoia? suicidal ideation? Do you know of any prior attempts? Have they ever articulated a plan to you? Have you done any safety planning with them? Any prior psychiatric hospitalization?
Any medications you recall them trying that seemed to have no effect, positive effects, or adverse effects? For instance- patient seemed to get worse on SSRI's, or patient benefited from ADHD medication but then sleep cycle was disrupted?
How would you rate this patient's ability to take ownership for their role in their challenges with 5 being the best?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How likely is this patient to actually take constructive feedback from you or this testing and implement it in their life?
Worst
1
2
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4
Best
5
1 is Worst, 5 is Best
Mood symptoms: What quality of symptoms do you tend to observe more with this particular patient? More depressive in nature (isolative, lack of motivation, hopeless, helpless, pessimistic, sad)? More anxious (impending feelings of doom, nervousness for no reason, always seeming to be in the future) Compulsions? Obsessions? Hypomania? Mania? Grandiosity? Lethargy? Euthymic? Dysthymic?
Any concerns around oppositionality? antisocial tendencies? being untrustworthy? stealing? destroying property? violence? aggression? manipulation? lack of empathy or compassion? lack of remorse?
How would you describe their appearance most times when in session
casual
neat
disheveled
odorous
well put together
concerned expression
laughs nervously frequently
dress seems inappropriate to age (younger or older)
cognitively impaired
emotionally blunted
agitated
irritable
talkative
quiet
How would you rate the client's desire for a rapid, easy solution to their problems rather than committing to deeper, long-term changes, with 5 being very likely seeking a "quick fix?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
What is their general approach towards therapy?
motivated
candid
open
honest
evasive
guarded
defensive
angry about being there
doesn't think they should be in therapy
Other
Any concerns you are noticing related to the autism spectrum for this patient?
social awkwardness
victim of bullying
deficits in adaptive functioning (not able to engage in same age peer activities such as grooming, hygiene, driving, occupational functioning)
maladaptive speech patterns
lack of social or emotional reciprocity
fixated interests in one particular topic
seems to talk "at" you vs. with you
not able to really identify any key friendships or reciprocal relationships
sensory issues with auditory input, tactile input, food pickiness, clothing issues, misophonia
doesn't seem to get humor, neologisms "its raining cats and dogs"
concrete or rigid thought processes
not flexible, transitions or change is extremely difficult
noted developmental delays when younger (speech, potty training, walking, talking)
twice exceptional abilities or sauvant like qualities
Thank you for taking the time to fill this out for your client. This info is tremendously helpful and your input is extremely important. If there is anything else that you would like to add, please do so below:
If you are still accepting patients in your practice, please provide the name of your practice, insurance accepted, and specialties/ages treated below. We use this to build our master referral list when referring our testing clients out, who don't already have therapists.
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