CCA Outline

Chief Complaint

1. “Why are you here”

2. “Why might someone else say you are here”

Treatment History

1. Who?
2. Where?
3. Do you know what you may have focused on?
4. What type of treatment did they offer? Cognitive Behavioral, DBT, etc.
5. Are you getting services from any other provider?

Describe factors that have contributed/inhibited previous recovery efforts

1. What was helpful?

2. What was not helpful?
3. What is your preferred learning style?
4. What is your preferred communication style (Direct, non-directive)?

Conditions/Diseases

1. Do you have any medical conditions?

2. Does it ever impact your day to day function? How so?

Injures

1. Have you ever broken, fractured anything?

2. Do you have any chronic physical limitations?
3. Who do you go to when you are injured? Sick? Do you have a primary care doctor?

Sleep Patterns

1. What time do you wake up?

2. What time do you go to bed?
3. Does it change on the weekend?
4. How long do you typically sleep?
5. Do you chronically feel tired?

Nutritional Patterns
 1. Do you eat at least three times a day? Why or why not?
2. Do you eat healthy or unhealthily?
3. Do you cook at home or eat out more?
4. Do you often feel hungry?
5. Do you tend to eat more during certain times? Day’s?
6. Does your mood impact your diet?

Diet for Past 2 Days

1. What is your diet for Past two days? (Breakfast Lunch and Dinner)
2. Any reason why you choose these?

Hearing and Visual

1. Do you wear glasses?

I. Are you near or far sighted?
II. Do you wear them all the time?
III. How long have you worn them?
IV. Who is your provider?

Patient History?

Family Psychiatric History

Does anyone in your family have a history of

A. Psychiatric illness,
B. Substance abuse
C. Intellectual/developmental disability,
D. Suicide
E. Domestic violence in biological and/or adopted family where applicable

Trauma History?

Describe history of sexual, physical, emotional abuse, or neglect. Can you think of anything that
your child may have experienced or witnessed that could have been very frightening or sad for
them? Describe any other historic traumatic events (e.g. active military duty, car accident, gun
shot, witness to traumatic event, etc.):

Work History
• Where do you work?
• How long have you worked there?
 • Do you get along with your colleagues?

Education History
• IEP
• Behavioral Plan
• Asking them their Learning Style (This can be very helpful to support clients in being able
to learn new skills)
• What were/are your grades like (Does/did your diagnosis impact them)

Relationship History

1. What are some of your current social supports? Who are your closest friends?): .

2. Have you ever been in an abusive/violent relationship?

3. Are you

A. Single
B. Married
C. Divorced?

4. Are you sexually active?

5. What is your sexual orientation?
6. What is your Gender expression?
7. How do you get along with siblings/parents/peers?
8. Are you interested in boys or girls romantically?
9. What are your relationships typically like; intense, short, long, rocky?

History of Hobbies/Extracurricular Activities

1. What activities do you play?

2. What interests do you have?
3. What would the perfect day be like?
4. What did you use to do that you would like to do again?
Legal/DSS/DJJ History

1. Any Current/prior involvement from DSS

Including
I. Custody disputes
II. What was the outcome of the DSS case?

2. Any current/prior involvement from DJJ

Including:
I. Probation
II. Parole
III. Court ordered treatment.
IV. Drug Charges?
V. Gun Charges?
VI. Sexually Based offenses?

Any charges: How long ago?

Cultural Beliefs/Identification

1. What is your ethnicity?

2. What is your family or self-culture?

A. Are there any cultural specific Intervention Strategies that you would like us to use
(Language; direct, non-directive, more or less facial expressions, etc)?

3. Do you have any Religious/Spiritual affiliation?

A. Is it important?
B. Do you attend services?

C. Do you use:

I. Crystals
II. Herbs
III. Tarot Cards
IV. Reiki
V. Seven chakras
VI. Yoga
VII. Personality tests (Myers Brigg’, etc.)
VIII. Enneagram

D. Would you like to incorporate any of these tools into treatment?

 E. Are there any identified value systems that are important either politically,
personally or culturally?

Strengths

1. What are at least three strengths?

2. Who are those who support you the most?
3. Any alternative health approaches that have been helpful?
4. Anything else that has helped you in getting through challenging times or
overcoming adversity?

Barriers

Are there any notable risk factors that you feel might impact treatment?
I. Negative relationships
II. Transportation issues
III. Economic issues
- Housing, day care, etc.

Goals and step down (in the client's words, what does he/she want to
accomplish/change?)

1. What would you like to accomplish?

2. What would be the “Ideal”
3. What are goals you have set in the past?
4. What would be a next step/ Transition?
5. Where are you currently at with this goal?
I. For review: where are you now?

Key for helping clients set goals

1. Specific
2. Measurable.
3. Attainable.
4. Relevant.
5. Time-bound.

Example of Goal setting Article

Treatment Recommendations & Supports (What services are being recommended

based on presenting information? What supports are recommended to be put in place to
help client achieve goals):
 Best ways for me to communicate with you
Directive or indirective feedback?
What has worked in the past (Any specific model)?

Are any of the following helpful?

- Worksheets,
- Visuals
- Fidgets
- Books
- Technology
- Metaphors
- Stories
- Videos
- Therapeutic Homework Assignments
- Quotes
- Games
- Physical Activity

Things to remember when doing the CCA

1. It is not a therapy session but is meant to be therapeutic

2. Ask Open ended questions
3. Don’t worry about complete sentences while writing it you can go back and fix it latter
4. Look for what impacts “Day to Day functioning” – why do they need services?
5. You can always do an update or amendment later

Summary (Example)

The Client is a (Give Age) 50-years- old (Give Race) white male and was (Give Reason for
Referral) referred for services by (Name referral source) due to (name specific parts of the
referral) Family stressors, depression, and increased symptoms of depression.

The Client is seeking support with a reduction in (Name Z Codes) and (triggers, trauma’s and
(psychiatric history) The client states that these stressors impact his/her symptoms of (Name
diagnosis with code) The client states that these symptoms include (Name symptoms, behaviors).
The client states that (Name impact on day to day functioning) are at their worse they can lead
him to feel excessive anger and not see the positives in situations and can impact lateral thinking.

The client notes that his (Name health issues, diseases, needs and concerns). The client has
indicated that they impact his treatment (Name treatment impact).
Despite the internal and external stressors, the client has noted that he has (Name Strength and a
time he/she was able use one). The client indicates that with these strengths it can help him with
(name weakness in a strength based manner and a time when it has been a challenge to use
one).In reference to times where his/her strengths/coping skills have not been successful is
(Name past trauma, hardest thing to cope with, persistent mental illness, etc).

The client indicates that (Name what is or has been helpful to services). On the opposite end of
this (Name what has not been successful, barriers (DHHS, criminal history, transportation,
fancies, etc]. During the session the client indicated that (name supports (family, friends,
religion, etc.), who they live with). The client does indicate that they (do/do not work (have or
have not), go to school/want to.

The client has stated that his/her goal for treatment is thus (Name Goal). Master's
Intern/Clinician recommends school/office/home based therapy (Place therapy will occur) for
youth/client up to 1/2/3 time per week (Frequency) or as needed to support the client in (What
you will support them with). Master's Intern/Clinician will utilize evidence-based practices
such as Person-Centered Therapy, Solution-Focused Therapy, Narrative Therapy, Cognitive
Behavioral Therapy (Mainly Beck's Cognitive Triad) (CBT), Relational-Cultural Therapy,
Structural Family Therapy, and Motivational Interviewing (MI) (Name and add what theory you
will use).

Click Here for a list of Z and V codes