PCS Intensive Pre-Screening Questions – Therapist

Name of Client (required)

Date Completed(required)

Completed By(required)

Please specify credentials(required)

If this is your first PCS referral how did you hear about us?(required)

1) Are you in agreement with your client attending the PCS intensive outpatient program?(required)

2) How long has he/she been a client of yours? (required)

3) Are you aware of your client attending other treatment facilities or hospitalized for mental health issues?(required)

4) Are you aware of any suicide attempts or current suicidal ideations? Homicidal ideation?(required)

5) Is the client taking any medications?(required)

6) What diagnosis code has the client been given?(required)

7) How has your client responded to trauma work? Are you aware of any levels of dissociation?(required)

8) Is substance abuse an issue for your client?(required)

9) Are you aware of any domestic violence? If so, please describe.(required)

10) Has your client done any disclosure, have they prepared for disclosure or are they anticipating doing disclosure anytime in the near future?(required)

11) What would you like to see your client accomplish while at PCS?(required)

12) What progress has your client made?(required)

13) What areas are challenging in your work with this client?(required)

14) Is the PCS intensive program your first recommendation for treatment for this client? (required)

14a) What other recommendations have you provided to this client for treatment and why? (required)

15) What kind of contact would you like from PCS during process?(required)

16) If PCS therapists thought clinically your client needed to stay an additional weekend or week, would you be in agreement? (required)

16a) Would you want to be contacted prior to this decision?(required)

17) How comfortable are you with PCS making specific treatment recommendations (i.e. interventionist, Amen clinic, 12-step groups, etc…).(required)

17a) Would you like to be contacted before recommendations are made? (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? (required)

If not please encourage client to do so.