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PCS Intensive Pre-Screening Questions – Therapist
PCS Intensive Pre-Screening Questions – Therapist
Name of Client
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(required)
Date Completed
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(required)
Completed By
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(required)
Please specify credentials
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(required)
If this is your first PCS referral how did you hear about us?
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(required)
1) Are you in agreement with your client attending the PCS intensive outpatient program?
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2) How long has he/she been a client of yours?
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(required)
3) Are you aware of your client attending other treatment facilities or hospitalized for mental health issues?
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(required)
4) Are you aware of any suicide attempts or current suicidal ideations? Homicidal ideation?
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5) Is the client taking any medications?
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6) What diagnosis code has the client been given?
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7) How has your client responded to trauma work? Are you aware of any levels of dissociation?
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8) Is substance abuse an issue for your client?
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9) Are you aware of any domestic violence? If so, please describe.
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10) Has your client done any disclosure, have they prepared for disclosure or are they anticipating doing disclosure anytime in the near future?
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11) What would you like to see your client accomplish while at PCS?
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(required)
12) What progress has your client made?
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13) What areas are challenging in your work with this client?
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14) Is the PCS intensive program your first recommendation for treatment for this client?
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14a) What other recommendations have you provided to this client for treatment and why?
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15) What kind of contact would you like from PCS during process?
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16) If PCS therapists thought clinically your client needed to stay an additional weekend or week, would you be in agreement?
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16a) Would you want to be contacted prior to this decision?
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17) How comfortable are you with PCS making specific treatment recommendations (i.e. interventionist, Amen clinic, 12-step groups, etc…).
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(required)
17a) Would you like to be contacted before recommendations are made?
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(required)
17b) Are you open to your client participating in the PCS alumni support group?
18) Do you have sessions scheduled with this client when they return from PCS?
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(required)
If not please encourage client to do so.