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MS Assessment Session
MS Assessment Session WU2299938 – LM
About Client
Therapist?
What for?
MS
Date of assessemnt
Client
DOB
Telephone
Email
Medically or physically able to work?
Can work
No
Yes
Need carer support
Physically unable to work
Medically unable to work
Other
Other
Any, mobility devices?
No
Crutches
Supporting frame
Manuel wheelchair
Scooter
Motorised wheelchair
Orthotic Devices
Other
Other
Assistive devices?
None
Electronic communication board
Eye tracking
Hearing
Adaptive writing & typing
Typing aids
Daily task assistive device
Other
Other
Medical Conditions
None
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Neurological Issues
Eyesight Problems
Hearing & Ear Problems
Heart Issues
Irritable Bowl Syndrome
Stroke
Other
Other
Medication
Any, counselling history?
None
NHS funded
Employment support
Self-paid
Other
Other
Approx Number of Sessions?
Approx year
Excluding the selected counselling above has the client had any other counselling?
Add in here any other counselling the client has had. If you selected NHS as example, you have inserted above. If the client also had self-paid insert in here with session number and year approx and so on.
Her/his experience of counselling?
Add in here if she felt it was beneficial or things like the counsellor did not understand my MS. Also add if the client was discharged as not suitable for there service. The idea of this box is a brief overview.
Assessment Session Report
This is now the assessment report from you
Any Past Suicide Attempts?
*
No
Yes
Any Current Suicidal Thoughts?
*
No
Yes
Do you feel so bad that they think of killing yourself?
*
No
Yes
Other
Do you feel so bad that they think of killing yourself?
Do You Feel Like Life is Not Worth Living?
*
No
Yes
Other
Do You Feel Like Life is Not Worth Living?
Have You Made Plans To End Your Life?
*
No
Yes
Other
Have You Made Plans To End Your Life?
Any thoughts Self Harm?
*
No
Yes
Any Self Harm Episodes?
*
No
Yes
Suicidal Risks? (Client Responce)
Self-Harm? (Client Responce)
Risk Other
Addictions?
Substance Abuse?
No
Yes
Other
Substance Abuse?
What? (Multi Select)
Cannabis
Cocaine
Social drugs
Alcohol
Prescription drugs
Pain killers
Other
Other
Canabis
Cannabis Severity
Mild
Moderate
Severe
Cannabis Frequency (based on a week)
Few Days
Most Days
Almost Every Day
Cannabis, how does it effect them?
As brief as possible.
Cocaine
Cocaine Severity
Mild
Moderate
Severe
Cocaine Frequency (based on a week)
Few Days
Most Days
Almost Every Day
Cocaine, how does it effect them?
As brief as possible.
Social Drugs (general)
Social drugs, severity
Mild
Moderate
Severe
Social drugs, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Social drugs, how does it effect them?
As brief as possible.
Alcohol
Alcohol severity?
Mild
Moderate
Severe
Drinking frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Prescription Drugs
Prescription drugs, severity
Mild
Moderate
Severe
Prescription drugs, frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Pain Killers
Pain killer,severity
Mild
Moderate
Severe
Pain killer, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Anything to add?
As brief as possible.
Other
Other, what?
Other, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Other, severity
Mild
Moderate
Severe
Other, how does it effect them?
As brief as possible.
Anxieties Mental Health? (Multi-Select Options)
Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only.
Anxieties
Generalised Anxiety
Panic Attacks
Stress
Obsessive-compulsive disorder (OCD)
Phobias
Post-traumatic stress disorder (PTSD)
Other
Other
General Anxiety
Anxiety, severity
Mild
Moderate
Severe
Anxiety, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Anxiety, how does it effect them?
As brief as possible.
Panic Attacks
Panic attacks, severity
Mild
Moderate
Severe
Panic attacks, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Panic attacks, how does it effect them?
As brief as possible.
Stress
Stress, severity
Mild
Moderate
Severe
Stress, frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
OCD
OCD, severity
Mild
Moderate
Severe
OCD, frequency (based on a week)
Few Days
Most Days
Almost Every Day
OCD, how does it effect them?
As brief as possible.
Phobias
Phobias, severity
Mild
Moderate
Severe
Phobias, frequency
Few Days
Most Days
Almost Every Day
Phobias, how does it effect them?
As brief as possible.
PTSD
PTSD, Severity
Mild
Moderate
Severe
PTSD, frequency (based on a week)
Few Days
Most Days
Almost Every Day
PTSD, how does it effect them?
As brief as possible.
Other
What?
Other, Severity
Mild
Moderate
Severe
Other, frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Depression Mental Health? (Multi-Select Options)
Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only.
Depressions
Generalised
SAD
Post-Natal
Other
Other
Generalised Depression
Depression, severity
Mild
Moderate
Severe
Depression, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Depression, how does it effect them?
As brief as possible.
Seasonal Affected Disorder
SAD Severity
Mild
Moderate
Severe
SAD, frequency (based on a week)
Few Days
Most Days
Almost Every Day
SAD, how does it effect them?
As brief as possible.
Post-natal Depression
PNT, severity
Mild
Moderate
Severe
PND, frequency (based on a week)
Few Days
Most Days
Almost Every Day
PNT, how does it effect them?
As brief as possible.
Other
Other, What?
Other, severity
Mild
Moderate
Severe
Other, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Other, how does it effect them?
As brief as possible.
Identity? (Multi-Select Options)
Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only.
Identity
Anger
Rage
Isolation
Low Self-esteem
Feelings of Discrimination
Other
Other
Anger or Rage
Anger, severity
Mild
Moderate
Severe
Anger, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Anger, how does it effect them?
As brief as possible.
Isolation
Isolation, severity
Mild
Moderate
Severe
Isolation, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Isolation, how does it effect them?
As brief as possible.
Low Self-Esteem
Low self-esteem, severity
Mild
Moderate
Severe
LSE – frequency (based on a week)
Few Days
Most Days
Almost Every Day
LSE, how does it effect them?
As brief as possible.
Discrimination
Discrimination, severity
Mild
Moderate
Severe
Discrimination, how does it effect them?
As brief as possible.
Other
What? (other)
Other, severity
Mild
Moderate
Severe
Other, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Other, how does it effect them?
As brief as possible.
Other? (Multi-Select Options)
Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only.
Other (this is not a diagnosis, its opinion based)
Insomnia
Interrupted Sleep
Poor Eating Habits
Bulimia
Anorexia
Poor Body Image
Body Dysmorphic Disorder
Chronic Pain
General Pain
Other
Other
Sleep
Sleep, severity
Mild
Moderate
Severe
Sleep, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Sleep, how does it effect them?
As brief as possible.
Food
Food issue?
Skip meals
Does not want to eat
Carer does not make the food
Overeating
Other
Other
Food, severity
Mild
Moderate
Severe
Food, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Anything to add?
As brief as possible.
Body Image
Poor body image, severity
Mild
Moderate
Severe
Body image, how does it effect them?
As brief as possible.
Pain
Pain, severity
Mild
Moderate
Severe
Pain frequency (based on a week)
Few Days
Most Days
Almost Every Day
What kind of pain and how does it effect them?
As brief as possible.
Other
Other what?
Other, severity
Mild
Moderate
Severe
Other, frequency (based on a week)
Few Days
Most Days
Almost Every Day
Other, how does it effect them?
As brief as possible.
Childhood through to 18
Childhood Issues? (Home)
No
Yes
What?
General
Bullying
General Abuse
Sexual Abuse
Poor Health
Mobility Issues
Other
Other
General
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Bullying
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
General Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Sexual Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Poor Health
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Other
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
School, College, University
Any Issues? (Education)
No
Yes
What?
General
Bullying
General Abuse
Sexual Abuse
Poor Health
Mobility Issues
Other
Other
General
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
General Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Bullying
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Sexual Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Poor Health
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Mobility Issues
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Other
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Relationships (as adult)
If required, multi-select relationship. In the box provided, you can elaborate.
Relationships (Romantic or Carers)
Live with (partner)
Carer (my carer)
Partner (not living with)
Guide or Assistance Animals
Pets
Other
Other
What?
No Issues
General
Bullying
General Abuse
Sexual Abuse
Financial Abuse
Control
Grief
Other
Other
General
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Bullying
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
General Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Sexual Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Financial Abuse
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Grief
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Control
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
Almost Every Day
How does it effect them?
As brief as possible.
Other
Severity
Mild
Moderate
Severe
Frequency (based on a week)
Few Days
Most Days
How does it effect them?
As brief as possible.
Would you like to add anything that is disability or injury specific?
Relevant to the application?
No
Yes
Summary
Recommendation?
Can you work with this client?
Yes
No
How many sessions do you recommend we apply for?
6-12
13-15
16-20
21-25
26-30
Other
How many sessions do you recommend we apply for?
Signature
Clear
If you are human, leave this field blank.
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