How to Develop and Conduct a Mental Health Assessment
Determine your assessment questions carefully., Study available background information., Set time limits on the assessment sessions., Establish the tentative number of sessions., Be consistent., Record information immediately., Be flexible., Take...
Step-by-Step Guide
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Step 1: Determine your assessment questions carefully.
Make your wording as clear as possible.
For example, if you ask "Do you hear things that others can't?" and the patient says yes, it could mean psychosis, or it could mean that they have very good hearing.
Consider the format.
For people who have difficulty reading, it may be best to read questions aloud, and use pictures to supplement.
Autistic people may struggle to understand and remember spoken words, so they can benefit from reading the questions. -
Step 2: Study available background information.
This may be done through direct observation, review of records or by interviewing people who know the individual.
Use this data in assessment design.
It will help in knowing how to set up these variables and possibly rewards in a way which will attract the individual to participate fully.
It will also indicate where, when and how to conduct the assessment to best obtain useful information for treatment planning. , If the session is too long, the participant may tire and lose focus, and you may lose keen observation due to the same.
Include the student in determining the length of the sessions.
Use a clock or visual timer so the student may track the passage of time without asking multiple times.
Inclusion in the process builds empowerment.
Even without intention, many times people on the autism spectrum feel disempowered.
It just happens by having a team of having so many adults making important decisions for them, even if the person is present at the meetings. , This may need to be altered depending on illness, other absences, and/or level of participation. , Show up on time, only interact to the degree allowed by the plan.
Remember that unless a part of the assessment, each unplanned interaction in some way alters the outcome of the assessment, or “skews the outcomes”. , Right after a session the information will be more detailed and complete than later on.
Be accurate in recording data.
It is extremely important to be objective, to note when you might be somewhat subjective, and to be detailed.
It is not always possible to record (video, auditory) the session.
As such, the accuracy of what you record is paramount.
Remember, you are the eyes and the ears for the rest of the treatment team.
Make sure to clearly highlight information that pertains directly to the assessment question(s). , Length of the assessment may vary.
A person may be slower to engage, or there may be more information than anticipated thereby altering the time required to complete the assessment.
If you are a professional conducting the assessment, you need to advise the team of your progress.
If you are not a professional, but are part of a larger team, bring any changes in the assessment to the team first before making change. , Provide feedback to the person so they are included in the process.
Gather every bit of information that has been recorded. , Break the report into sections such as:
Background to the assessment.
Acknowledgment of the assessment questions.
How the assessment was set up.
Always include how the person presented on the first day.
Interested or not, well groomed and dressed or not, communicative or not? The initial contact is important as it provides baseline information that will not otherwise be included in the report.
Answer each assessment questions thoroughly, as well as anything that stands out as very significant that the questions did not cover. ,,, If you are a consulting professional, ensure that the team has a direction to move in once the assessment is complete.
Provide suggestions and/or alternatives to treatment planning and development. -
Step 3: Set time limits on the assessment sessions.
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Step 4: Establish the tentative number of sessions.
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Step 5: Be consistent.
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Step 6: Record information immediately.
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Step 7: Be flexible.
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Step 8: Take time to share the results.
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Step 9: Write a comprehensive
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Step 10: readable assessment report.
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Step 11: Write a summary to the assessment.
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Step 12: Sign it
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Step 13: date it
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Step 14: distribute copies to team members.
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Step 15: Offer recommendations.
Detailed Guide
Make your wording as clear as possible.
For example, if you ask "Do you hear things that others can't?" and the patient says yes, it could mean psychosis, or it could mean that they have very good hearing.
Consider the format.
For people who have difficulty reading, it may be best to read questions aloud, and use pictures to supplement.
Autistic people may struggle to understand and remember spoken words, so they can benefit from reading the questions.
This may be done through direct observation, review of records or by interviewing people who know the individual.
Use this data in assessment design.
It will help in knowing how to set up these variables and possibly rewards in a way which will attract the individual to participate fully.
It will also indicate where, when and how to conduct the assessment to best obtain useful information for treatment planning. , If the session is too long, the participant may tire and lose focus, and you may lose keen observation due to the same.
Include the student in determining the length of the sessions.
Use a clock or visual timer so the student may track the passage of time without asking multiple times.
Inclusion in the process builds empowerment.
Even without intention, many times people on the autism spectrum feel disempowered.
It just happens by having a team of having so many adults making important decisions for them, even if the person is present at the meetings. , This may need to be altered depending on illness, other absences, and/or level of participation. , Show up on time, only interact to the degree allowed by the plan.
Remember that unless a part of the assessment, each unplanned interaction in some way alters the outcome of the assessment, or “skews the outcomes”. , Right after a session the information will be more detailed and complete than later on.
Be accurate in recording data.
It is extremely important to be objective, to note when you might be somewhat subjective, and to be detailed.
It is not always possible to record (video, auditory) the session.
As such, the accuracy of what you record is paramount.
Remember, you are the eyes and the ears for the rest of the treatment team.
Make sure to clearly highlight information that pertains directly to the assessment question(s). , Length of the assessment may vary.
A person may be slower to engage, or there may be more information than anticipated thereby altering the time required to complete the assessment.
If you are a professional conducting the assessment, you need to advise the team of your progress.
If you are not a professional, but are part of a larger team, bring any changes in the assessment to the team first before making change. , Provide feedback to the person so they are included in the process.
Gather every bit of information that has been recorded. , Break the report into sections such as:
Background to the assessment.
Acknowledgment of the assessment questions.
How the assessment was set up.
Always include how the person presented on the first day.
Interested or not, well groomed and dressed or not, communicative or not? The initial contact is important as it provides baseline information that will not otherwise be included in the report.
Answer each assessment questions thoroughly, as well as anything that stands out as very significant that the questions did not cover. ,,, If you are a consulting professional, ensure that the team has a direction to move in once the assessment is complete.
Provide suggestions and/or alternatives to treatment planning and development.
About the Author
Amber Rivera
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