Termination Face Sheet
Case File #:______Date Form Received: ______
Date of Last Session: ______
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Religion: Sexual Preference:
protestant heterosexual
catholic homosexual
jewish bisexual
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muslim
none
other
Relationship Status: Lives with: Number of Children: ______
single alone Birthdates or Ages of Children: ______
married spouse Lives with Children:
living with partner significant other yes no
divorced parents
separated roommates
widowed
Highest degree (circle): HS dip / BA / MA / MFA / PhD / MD / JD / MBA
Occupation: ______
Annual Income:______
Current fee per session: $______Date fee last reviewed: ______
Fee Basis: clinic pay private pay
Is patient using couch? yes no Weekly session frequency: ______
Is patient on medication? yes no (if yes, please update the Flow Sheet)
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Alcohol Use: yes no (amount per day) ______
if yes: type quantity/frequency when began
Smoker: yes no (packs per day)______
Caffeine Intake: (per day)______
Current Drug Use: yes/no
if yes: type quantity/frequency when began
Patients capacity to reflect on own and others inner states and motivations (please rate):
0 no capacity
1
2
3
4 psychologically minded, able to reflect
Timing of Termination*:
Did the treatment (select one)
End abruptly
Come to a planned termination
Convert to psychotherapy
Number of months from decision until final session ______.
*(We define a planned termination as a mutually agreed upon ending of the treatment, for any reason, in which a date for the termination was set at least three months in advance of the actual ending; we define an abrupt ending as one in which the patient, or analyst, makes the decision to end the treatment without allowing at least three months time between setting the date and ending the treatment.)
Reason for termination (select all that apply):
Treatment complete
Patient’s life events
Analyst’s life events
Patient wishes to end treatment despite analyst’s feelings to the contrary
Patient impulsively ends the analysis or behaves (“acts out”) in such a way as to force the analyst to end the treatment
Analyst decides to end the analysis because s/he feels that the patient is unlikely to make further gains
Analyst’s assessment of outcome:
Analytic Process was established:
0 no analytic process
1
2
3
4 analytic process was established and sustained most of the time through the middle and later phases of the analysis.
Patient made therapeutic gains:
0 Treatment ended with patient in crisis
1 Became more symptomatic
2 Little or no change
3 Fair
4 Excellent-good
Medication Management:
Is patient on medication at the end of treatment: yes no
Who is going to prescribe the medication after the analysis ends?
the analyst
private psychiatrist (other than the analyst)
patient’s internist
a clinic
Further Psychotherapeutic Treatment:
Is the patient going to be in any kind of psychotherapy after ending analysis? yes no
If yes:
Individual psychotherapy if this, at what frequency? _____/week.
Group psychotherapy
Couples therapy
who will be the provider of this treatment?
analyst
another therapist
DIAGNOSIS AT TERMINATION:
DSM-IV diagnosis:
Current Axis I:
Past Axis I: (no longer active)
Axis II
Axis III:
Axis IV: none mild moderate severe
Axis V: (please note number from 10-90 as per DSM IV): ______
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Psychoanalytic character diagnosis (descriptive diagnosis):
Select from the list below:
a. Most prominent character style
(Select one only)
antisocial
avoidant
borderline
dependent
depressive
hysterical
infantile/hysteroid
masochistic
narcissistic
obsessional
paranoid
passive aggressive
sadomasochistic
schizoid
schizotypal
b. Prominent additional features
(Mark “1”, “2”, or “3” in descending order of importance)
___ antisocial
___ avoidant
___ borderline
___ dependent
___ depressive
___ hysterical
___ infantile/hysteroid
___ masochistic
___ narcissistic
___ obsessional
___ paranoid
___ passive aggressive
___ sadomasochistic
___ schizoid
___ schizotypal
Narcissistic Pathology:
If you checked narcissistic in a or b above, which most accurately describes this patient (select one only)
Narcissistic personality
Prominent narcissistic defenses in the absence of a narcissistic personality
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Predominant level of structural organization (structural diagnosis):
(Select one only)
Neurotic
Borderline
Psychotic
If Neurotic, Borderline Features are Present Absent
Key to Level of Psychological Organization
Psychotic
· Reality testing is impaired or easily lost under stress.
· Poorly consolidated sense of self (identity diffusion)
· Object representations are poorly integrated (part objects)
· Relies primarily on combination of psychotic and primitive defenses, although higher level defenses may also be present.
Borderline
· Reality testing is generally intact but may be transiently lost under stress or in regressive settings
(e.g., transference psychosis)
· Poorly consolidated sense of self (identity diffusion) or more stable, but pathological sense of self
(pathological grandiose self)
· Object representations are poorly integrated (part objects)
· Relies primarily on primitive defenses, although higher level defenses may also be present
Neurotic
· Reality testing is intact
· Well consolidated sense of self (consolidated identity/ No identity diffusion)
· Object representations are well integrated (whole objects)
· Relies primarily on higher level defenses, although primitive defenses may also be present
Number of supervisory sessions per month: ______
Did you change supervisors in the last year? yes no
Has supervisor discussed the yearly write-up with you? yes no
Has supervisor discussed your supervisory evaluation with you? yes no
Analyst: ______
Supervisor: ______
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