Getting Oriented to the Clinician's Thesaurus |
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1 | (1) |
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What Is the Clinician's Thesaurus and What Does It Do? |
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1 | (1) |
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How This Book Is Organized |
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2 | (1) |
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Understanding the Style and Format of the Chapters |
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3 | (5) |
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A Functional Guide to Report Construction |
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8 | (6) |
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Further Guidelines and Advice on Report Writing |
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14 | (2) |
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Some Ways to Use the Clinician's Thesaurus |
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16 | (1) |
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A Cautionary Note and Disclaimer |
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17 | (4) |
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PART I. Conducting a Mental Health Evaluation |
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Beginning and Ending the Interview |
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21 | (4) |
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Structuring the Interview |
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21 | (1) |
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Introducing Yourself and Noting Possible Communication Difficulties |
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21 | (1) |
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Assessing the Client's Understanding of the Interview Situation |
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22 | (1) |
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Obtaining Informed Consent |
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22 | (1) |
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Other Points for All Interviews |
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23 | (1) |
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Eliciting the Chief Concern/Complaint/Issue |
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23 | (1) |
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Eliciting the Client's Understanding of the Problem |
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23 | (1) |
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Dimensionalizing the Concern/Problem |
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24 | (1) |
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24 | (1) |
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Mental Status Evaluation Questions/Tasks |
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25 | (17) |
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Introduction to the Mental Status Questions |
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25 | (1) |
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Background Information Related to Mental Status |
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26 | (1) |
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Rancho Los Amigos Cognitive Scale |
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26 | (1) |
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27 | (1) |
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27 | (1) |
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28 | (1) |
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29 | (1) |
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Comprehension of Language |
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29 | (1) |
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Eye-Hand Coordination/Perceptual-Motor Integration/Dyspraxia/Constructional Ability |
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30 | (1) |
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30 | (2) |
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32 | (2) |
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34 | (1) |
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34 | (1) |
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34 | (1) |
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35 | (1) |
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35 | (1) |
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Abstract Reasoning/Proverbs |
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36 | (1) |
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37 | (1) |
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37 | (1) |
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38 | (1) |
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38 | (1) |
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39 | (1) |
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39 | (1) |
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Mental Status Evaluation Checklist |
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39 | (3) |
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Questions about Signs, Symptoms, and Other Behavior Patterns |
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42 | (37) |
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Introduction to the Questions about Signs, Symptoms, and Behavior Patterns |
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42 | (1) |
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Abuse (Nonsexual)/Neglect of Spouse/Elder |
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43 | (1) |
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Abuse (Nonsexual)/Neglect of Child |
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44 | (1) |
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Abuse (Sexual) of Child or Adult |
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44 | (1) |
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45 | (1) |
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46 | (1) |
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Compliance--Noncompliance with Treatment |
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46 | (1) |
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46 | (1) |
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47 | (2) |
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49 | (1) |
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50 | (1) |
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51 | (2) |
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Gay and Lesbian Identity Formation |
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53 | (1) |
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53 | (2) |
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55 | (1) |
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55 | (1) |
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55 | (1) |
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56 | (1) |
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Organicity/Cognitive Disorders |
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57 | (1) |
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57 | (1) |
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58 | (1) |
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59 | (1) |
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59 | (1) |
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59 | (3) |
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Sexual Identity/Transgender Issues |
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62 | (1) |
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62 | (2) |
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Substance Abuse: Drugs and Alcohol |
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64 | (8) |
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Substance Use: Tobacco and Caffeine |
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72 | (1) |
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Suicide and Self-Destructive Behavior |
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72 | (7) |
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PART II. Standard Terms and Statements for Wording Psychological Reports |
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A. Introducing the Report |
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Beginning the Report: Preliminary Information |
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79 | (8) |
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Heading and Dates for the Report |
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79 | (1) |
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Sources of Information for the Report |
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80 | (1) |
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Identifying Information about the Client |
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80 | (2) |
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Self-Sufficiency in Appearing for Examination |
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82 | (1) |
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82 | (1) |
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83 | (2) |
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85 | (2) |
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87 | (5) |
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Statement of Referral Reason |
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87 | (1) |
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Common Referral Reasons for Children at Home |
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88 | (1) |
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Common Referral Reasons for Children at School |
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88 | (2) |
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Common Referral Reasons for Children at Both Home and School |
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90 | (2) |
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Background Information and History |
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92 | (11) |
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History/Course of the Present/Chief Complaint/Concern/Problem/Illness |
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92 | (1) |
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Medical History and Other Findings |
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93 | (1) |
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Personal, Family, and Social Histories, and Current Social Situation |
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94 | (3) |
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97 | (1) |
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Social History for a Disability Examination |
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98 | (1) |
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Family Genogram/Family Tree/Pedigree |
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98 | (5) |
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B. The Person in the Evaluation |
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103 | (11) |
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103 | (3) |
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106 | (1) |
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107 | (1) |
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108 | (2) |
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110 | (3) |
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Other Behavioral Observations |
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113 | (1) |
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Responses to Aspects of the Examination |
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114 | (8) |
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Reaction to the Context of the Evaluation |
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114 | (2) |
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Attention/Concentration/Effort |
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116 | (1) |
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Response to the Methods of Evaluation/Tests/Questions |
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117 | (1) |
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118 | (1) |
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Relationship with the Examiner |
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119 | (2) |
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Response to Success/Failure/Feedback |
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121 | (1) |
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122 | (5) |
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122 | (1) |
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122 | (1) |
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123 | (1) |
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Social Sophistication/Manners |
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124 | (1) |
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124 | (1) |
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Other Aspects of Self--Presentation |
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124 | (3) |
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Emotional/Affective Symptoms and Disorders |
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127 | (14) |
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General Aspects of Mood and Affects |
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127 | (1) |
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128 | (1) |
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129 | (2) |
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131 | (1) |
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131 | (1) |
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131 | (1) |
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132 | (4) |
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136 | (1) |
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137 | (2) |
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139 | (1) |
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Seasonal Affective Disorder |
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139 | (1) |
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139 | (1) |
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Other Affects/Emotional Reactions |
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140 | (1) |
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Cognition and Mental Status |
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141 | (17) |
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No Pathological Findings: Summary Statements |
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141 | (1) |
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142 | (1) |
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142 | (1) |
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Concentration/Task Persistence |
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142 | (1) |
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143 | (1) |
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143 | (1) |
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144 | (1) |
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145 | (1) |
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145 | (1) |
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Intelligence, Development, and Cognition: Assessment |
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146 | (2) |
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Intelligence Scores: Classifications |
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148 | (1) |
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148 | (3) |
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Moral/Social Judgment and Knowledge |
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151 | (1) |
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Motivation for Change: Summary Statements |
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152 | (1) |
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152 | (1) |
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152 | (1) |
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Reasoning/Abstract Thinking/Concept Formation |
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153 | (1) |
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154 | (1) |
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154 | (3) |
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Test Judgment: Summary Statements |
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157 | (1) |
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Other Summary Statements for Mental Status |
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157 | (1) |
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Abnormal Signs, Symptoms, and Syndromes |
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158 | (41) |
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158 | (1) |
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159 | (1) |
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Attention-Deficit/Hyperactivity Disorder |
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159 | (3) |
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Autsim Spectrum Disorders |
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162 | (1) |
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163 | (1) |
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164 | (1) |
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165 | (1) |
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165 | (1) |
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166 | (1) |
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167 | (1) |
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Depersonalization and Deralization |
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168 | (1) |
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168 | (1) |
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168 | (3) |
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171 | (1) |
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171 | (1) |
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172 | (1) |
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173 | (1) |
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174 | (1) |
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Impulse Control Disorders |
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174 | (2) |
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176 | (2) |
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178 | (1) |
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Oppositional Defiant Disorder |
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178 | (1) |
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Pain Disorder/Chronic Pain Syndrome |
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178 | (2) |
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180 | (1) |
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180 | (1) |
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Premenstrual Dysphoric Disorder |
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180 | (1) |
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181 | (1) |
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Posttraumatic Stress Disorder |
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182 | (1) |
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183 | (1) |
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184 | (1) |
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School Refusal/Avoidance/``Phobia'' |
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185 | (1) |
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185 | (1) |
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186 | (1) |
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Sexual Impulsivity/``Addiction''/``Compulsion'' |
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187 | (1) |
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Side Effects of Psychotropic Medications/Adverse Drug Reactions |
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187 | (1) |
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188 | (2) |
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190 | (1) |
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Substance Use, Abuse, and Dependence |
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190 | (4) |
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194 | (5) |
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199 | (30) |
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Assessment of Personality |
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199 | (2) |
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Cognitive or Thinking Styles |
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201 | (1) |
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Interpersonal Diagnoses of Personality |
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202 | (1) |
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A and B Personality Types |
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202 | (1) |
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``Addictive'' Personality |
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203 | (1) |
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204 | (1) |
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204 | (2) |
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Authoritarian Personality |
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206 | (1) |
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207 | (1) |
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207 | (2) |
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209 | (2) |
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211 | (1) |
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212 | (2) |
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Dissociative Identity Disorder |
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214 | (1) |
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215 | (1) |
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Hypochondriacal Personality |
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216 | (1) |
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217 | (1) |
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218 | (1) |
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Normal/Healthy Personality |
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219 | (1) |
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220 | (1) |
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221 | (2) |
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Passive-Aggressive Personality |
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223 | (1) |
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223 | (1) |
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224 | (1) |
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225 | (1) |
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Self-Defeating Personality |
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225 | (4) |
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C. The Person in the Environment |
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Activities of Daily Living |
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229 | (5) |
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229 | (1) |
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Assistance Level Required |
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229 | (1) |
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230 | (1) |
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Chores/House Care/Domestic Skills |
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230 | (1) |
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230 | (1) |
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230 | (1) |
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Hazard Recognition and Coping |
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231 | (1) |
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Living Situation/Level of Support Needed |
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232 | (1) |
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232 | (1) |
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232 | (1) |
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233 | (1) |
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233 | (1) |
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233 | (1) |
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Social/Community Functioning |
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234 | (2) |
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234 | (1) |
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Involvement in Social/Community Activities |
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235 | (1) |
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Problems/Conflicts in Community Relating |
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235 | (1) |
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Couple and Family Relationships |
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236 | (5) |
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Assessment of Families at Intake |
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236 | (2) |
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Child Rearing/Raising: Aspects |
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238 | (1) |
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Couple Relationships: Aspects |
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238 | (1) |
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Family Interviewing Method |
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239 | (1) |
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Systemic Family Evaluations |
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240 | (1) |
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Vocational/Academic Skills |
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241 | (7) |
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241 | (3) |
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244 | (1) |
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Language Skills: Reading and Writing Ability |
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244 | (1) |
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245 | (1) |
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Special Considerations for Disability Reports |
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246 | (1) |
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Vocational Competence/Recommendations |
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246 | (2) |
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248 | (2) |
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Entertainment: TV/Radio/Music |
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248 | (1) |
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248 | (1) |
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Participation/Performance Quality |
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248 | (1) |
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249 | (1) |
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249 | (1) |
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Other Specialized Evaluations |
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250 | (11) |
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Coping Ability/Stress Tolerance |
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250 | (1) |
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Culturally Sensitive Formulations |
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250 | (2) |
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252 | (1) |
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Financial Competence/Competence to Manage Funds |
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252 | (1) |
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Homosexual Identity: Stages of Formation |
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253 | (1) |
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Impairment's Effects on a Person |
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254 | (1) |
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254 | (1) |
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255 | (1) |
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Religious and Spiritual Concerns |
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256 | (1) |
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Testamentary Competence/Competence to Make a Will |
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257 | (4) |
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Summary of Findings and Conclusions |
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261 | (3) |
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261 | (1) |
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261 | (1) |
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Summary of Previous Information |
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261 | (1) |
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Relevant Findings and/or Conclusions |
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262 | (1) |
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262 | (1) |
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Consultations and Further Evaluations |
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262 | (1) |
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262 | (2) |
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Diagnostic Statement/Impression |
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264 | (27) |
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264 | (1) |
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264 | (1) |
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265 | (1) |
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265 | (1) |
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266 | (3) |
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Stress and Adjustment Disorders |
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269 | (1) |
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270 | (1) |
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Impulse-Control Disorders Not Elsewhere Classified |
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271 | (1) |
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271 | (4) |
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Eating and Elimination Disorders |
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275 | (1) |
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``Organic'' Cognitive Conditions |
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275 | (3) |
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Substance--Related Disorders |
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278 | (4) |
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282 | (1) |
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283 | (1) |
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284 | (1) |
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Psychological Factors Affecting a Medical Condition |
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284 | (1) |
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285 | (1) |
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Sexual Dysfunctions and Disorders |
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286 | (2) |
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288 | (1) |
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Medication-Induced Movement Disorders |
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288 | (1) |
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288 | (2) |
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Axis IV: Psychosocial and Environmental Problems |
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290 | (1) |
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Axis V: Global Assessment of Functioning Scale |
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290 | (1) |
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291 | (5) |
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291 | (1) |
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292 | (1) |
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Treatment Options/Case Disposition |
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293 | (1) |
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Types of Therapies/Services |
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294 | (2) |
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296 | (2) |
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General Prognostic Statement |
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296 | (1) |
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296 | (2) |
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298 | (5) |
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298 | (1) |
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298 | (1) |
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298 | (1) |
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299 | (4) |
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PART III. Useful Resources |
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Treatment Planning and Treatment Plan Formats |
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303 | (20) |
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The Flow and Nature of Treatment Planning |
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303 | (1) |
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Some Advice on Writing Treatment Plans |
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303 | (1) |
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Various Formats for Treatment Plans |
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304 | (4) |
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A Treatment Plan Format for Managed Care Organizations |
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308 | (10) |
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Treatment Plan Components for Clients with Substance Abuse |
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318 | (2) |
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Treatment Plan Components for Crisis Interventions |
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320 | (1) |
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320 | (1) |
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Outcome Measures/Goal Achievements |
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321 | (2) |
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Formats for Reports, Evaluations, and Summaries |
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323 | (11) |
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A Standard Format for Reports of Evaluations |
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323 | (1) |
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Format for Psychodynamic Evaluations: Developmental Model |
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324 | (1) |
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Format for Psychodynamic Evaluations: Structural Model |
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325 | (1) |
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326 | (1) |
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Themes for Evaluations from an Existential Perspective |
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327 | (1) |
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328 | (1) |
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329 | (1) |
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Nursing Diagnoses and Treatment Planning |
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329 | (1) |
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330 | (1) |
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Vocational and Nonclinical Personality Evaluations |
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331 | (1) |
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Formats for Therapy Notes |
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332 | (2) |
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Treatments for Specific Disorders and Concerns |
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334 | (5) |
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Abuse/Aggression/Violence/Impulsive Behaviors |
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334 | (1) |
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Attention-Deficit/Hyperactivity Disorder |
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334 | (1) |
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Anorexia Nervosa and Bulimia Nervosa |
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335 | (1) |
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335 | (1) |
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335 | (1) |
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335 | (1) |
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Borderline Personality Disorder |
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335 | (1) |
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335 | (1) |
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Dissociative Identity Disorder |
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335 | (1) |
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336 | (1) |
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336 | (1) |
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Hypochondriacal Personality |
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336 | (1) |
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Neuroleptic Malignant Syndrome |
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336 | (1) |
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Obsessive--Compulsive Disorders |
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336 | (1) |
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336 | (1) |
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337 | (1) |
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Posttraumatic Stress Disorder |
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337 | (1) |
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Religious and Spiritual Concerns |
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337 | (1) |
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Schizophrenia and Psychosis |
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337 | (1) |
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337 | (1) |
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Strengths and Positive Psychology |
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338 | (1) |
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338 | (1) |
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338 | (1) |
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Listing of Common Psychiatric and Psychoactive Drugs |
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339 | (7) |
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Listing of Medications by Both Trade and Generic Names |
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339 | (5) |
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Finding Street Drugs' Names |
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344 | (1) |
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Results of Medication Treatment: Descriptors |
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344 | (1) |
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Resources for the Clinician |
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345 | (1) |
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Psychiatric Masquerade of Medical Conditions |
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346 | (13) |
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346 | (1) |
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346 | (1) |
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347 | (1) |
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347 | (1) |
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348 | (1) |
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Organic Brain Syndrome/Dementia |
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348 | (2) |
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350 | (1) |
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Medication-Induced Psychiatric Conditions |
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350 | (3) |
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Abbreviations in Common Use |
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353 | (4) |
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Clinicians/Mental Health Professionals |
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353 | (1) |
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354 | (1) |
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355 | (1) |
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355 | (1) |
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General Aids to Recording |
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355 | (1) |
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356 | (1) |
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356 | (1) |
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356 | (1) |
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Annotated Readings in Assessment, Interviewing, and Report Writing |
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357 | (2) |
Feedback Solicitation Form |
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359 | (2) |
About the Clinician's Electronic Thesaurus, Version 6.0 |
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361 | (2) |
References |
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363 | (8) |
Index |
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371 | |