Risk screening and assessment are important components of establishing a client’s clinical baseline and identifying concerns that may affect safety, clinical stability, treatment, and outcomes.
When you begin working with a new client, the Initial Diagnostic Assessment provides an opportunity to gather information about the client’s current presentation, history, and context while establishing a baseline for ongoing risk monitoring.
What should I assess at intake?
Clinical best practice frameworks indicate that the Initial Diagnostic Assessment should include:
- Presenting concerns and symptoms
- Psychiatric/mental health, medical, and substance use history
- Psychosocial and environmental context
- Risk and protective factors
- Mental Status Exam (MSE)
- Diagnostic formulation and treatment planning
This information can help you understand the client's current functioning and identify factors that may require additional assessment or monitoring.
How should I use information gathered at intake?
Risk identified during the intake process should inform:
- The treatment plan
- Safety planning
- Follow-up needs
- Consideration of whether the current level of care is appropriate
The Initial Diagnostic Assessment establishes a baseline that can help you recognize meaningful changes in the client's presentation over time.
💡Remember: Risk assessment is not a one-time task. Risk should continue to be evaluated throughout treatment as clinically appropriate.