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Taking History – Backbone of Counseling
Here in this post, we are discussing “Taking History”. Keep visiting Psychology Roots.
Taking History
Taking history is a process through which therapists gather information by asking particular questions to the client. The gathered information is useful for the medical care & diagnosis purpose of the client.
Taking History
Common Steps
1. Identifying Information.
Patient’s name or any other name patient prefers to call with.
2. Introduce yourself.
Take consent to speak, built rapport by ensuring that all the gathered information is kept confidential.
3. Presenting problem.
Purpose of visiting the mental health care. Client’s condition in his own words, how he feels about the problem and how much disturbed with it.
4. History of Presenting Complaint.
How long the client is suffering from the presenting problem.
5. Previous Medical History.
Ask about any other medical issue client had suffered from before presenting complaint.
6. Medication.
The client’s beliefs about their medication can give useful insight into what they believe is wrong with them. Remember to ask about side effects and compliance
7. Prior Psychiatric History.
Except for the recent problem, has the client experience any other psychiatric illness before, this might help in building a link between the past and present complain.
8. Family History.
Information about family history helps in identifying the problem by knowing the client’s relationship with the family member.
9. Personal Social History.
It includes birth order, childhood & school life experiences, Job status, psychosexual history and drug usage.
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