Initials:

Age: Weight: Ethnicity: Race: Allergies:

Occupation: Family Constellation:

Living Situation:

Presenting complaint:

History of present illness:

Characteristics of Personality Disorder

The characteristics of a personality disorder are impairments in self and interpersonal functioning, and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

•Substantial impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

•One or more pathological personality trait domains or trait features

•These impairments in personality functioning and the individual’s personality traits are relatively stable across time and situation

•These impairments in personality functioning and personality trait expression are not considered as normal for the individual’s developmental stage or socio-cultural environment

•These impairments in personality function and trait expression are not due to the physiological effects of a medical condition or substance (APA, 2013).

Patterns of behavior (self-harm, alcohol, drug use, Addiction (shopping, gambling, pornography, video, gaming, etc.):

Shoplifting:

Legal issues:

Interpersonal functioning and relatedness:

Alterations in cognition:

Current and recent stressors:

Current coping skills:

Spirituality and/or religion:

Client and family’s perception of problem:

Past medical history (medical history, treatment and outcomes, recent and past hospitalizations, surgeries):

Family medical history:

Medications (side effects, adverse side effects, and treatment response) INCLUDE BELIEFS about medications

Non-prescription drugs/OTC:

Substance use history (for each substance, identify the type and details to include: duration, frequency, last use; blackouts; withdrawal seizures; drug-related psychosis).

Legal, psychosocial, physical, interpersonal, and occupational consequences.

Smoking history:

Alcohol use:

Marijuana use:

Illicit drugs:

Herbals:

Complementary treatments:

Include exposure to prescription opioids (reasons for use, pain, duration, frequency etc.)

Psychotropic medications, side effects, adverse side effects, and treatment response:

Past psychiatric history (psychiatric history/treatment and outcomes, recent and past psychiatric or substance abuse hospitalizations, residential or outpatient treatments):

Family psychiatric history and/or substance use history:

Sociocultural history (family and social history, work history, current employment, volunteer work, legal history, active and past, current support system, marital status, and children):

Trauma history:

Trauma exposure (childhood abuse or neglect, rape or sexual assault, emotional abuse, domestic violence, military/combat service, and natural disasters, historical/political trauma):

History of head injury, loss of consciousness, seizures:

COMPREHENSIVE TREATMENT PLAN:

INCLUDE EVIDENCED- BASED THERAPEUTIC MODALITIES FOR THE IDENTIFIED PERSONALITY DISORDER