First, the basic information of visitors
Name, gender, age, marriage, occupation, education level, native place, address, contact information, etc.
Second, the reasons and expectations of consultation
Consultation appointment method: make an appointment by yourself, family or others, etc. And the date of the first consultation. Reasons for seeing a doctor: main consultation questions, consultation expectations, and goals that I hope to achieve through consultation.
Third, the current medical history
Describe the occurrence and development of psychological problems of current visitors in chronological order. Focus on understanding visitors' thoughts, emotional expressions, behavioral responses, and the results of interaction with the environment after life events, and evaluate visitors' social functions and physiological conditions.
Fourth, the past history.
Describe the related situation before the current psychological problems of the visitors in chronological order. This includes (1) past physical illness history, (2) past mental illness history and (3) past psychological counseling history.
The growth history of verb (verb's abbreviation)
According to the personal growth process (infancy, primary school, junior high school, senior high school, university, employment), describe the relevant life events, focusing on the impact of these life events on individuals and the changes that have taken place from them.
Sixth, the history of interpersonal relationships.
Describe interpersonal relationships at different times and levels and their influence on visitors. These include: (1) the relationship between childhood visitors and family of origin members and their influence on themselves; (2) The interaction between visitors and each member of family of origin at this stage; (3) various relationships in the family (husband and wife relationship, parent-child relationship, etc.). ); (4) Interpersonal relationships and important influential figures in different periods.
Seven, psychological examination
Including two aspects (1) observation impression: mainly describing whether the visitor is on time (or in advance), appearance (charm/defect), body shape (fat, thin, strong, etc. ), clothing (neat or not), dress (whether it conforms to identity, weird and trendy), posture and movements (lettering movements, unconscious movements, etc.). ). Interactive relationship (cooperation, resistance) and attitude (equality, respect, etc. ) Relationship with consultants and others in the same trade (conflict, obedience, etc. (2) psychological evaluation results: describe the test name and test results.
Eight, psychological diagnosis
1. Evaluate visitors from the following six aspects: (1) social function, (2) physiological status, (3) behavioral status, (4) emotional status, (5) cognitive status and (6) personality/self-concept. 2. Give the diagnosis and its basis. The differential diagnosis instructions are given.
Nine. Consulting project
1. Analyze the causes of psychological problems of visitors, point out the key of psychological counseling, and determine the goal of psychological counseling. 2. Principles and main technical methods of psychological counseling. The stage and process arrangement of psychological consultation.
X. Evaluation of consultation results
Re-evaluate six aspects of visitors.
Xi。 Postscript of consultant
Psychological counselors' experiences and related insights in the process of psychological counseling.
Attachment: Pre-consultation Record Form