Follow-Up Packets

Please fill out this baseline packet to the best of your ability

Please note that some questions default to “No,” you only need to change to “Yes” if applicable.

Basic Data
Client Code
Date Completed this Form
Follow-Up Type

Summary of CEDAR Treatment
Please indicate the client’s reason for discharge/leaving the CEDAR Clinic:
Did the client participate in any CEDAR treatment?
If So, please indicate what treatments
Individual Therapy?
Psychopharmacology?
Family Treatment?
Coaching?
So far in treatment, approximately how many total sessions of each of the following types of services did the client attend?
Individual Therapy
Psychopharmacology
Family Treatment
Coaching
On average, how often did the client cancel or reschedule each of the following types of services?
Individual Therapy
Psychopharmacology
Family Treatment
Coaching
On average, how engaged was the client during each of the following types of meetings? (Note: please focus on client’s engagement/behavior during sessions attended, rather than frequency of sessions or cancellations.)
Individual Therapy
Psychopharmacology
Family Treatment
Coaching
Overall, how much progress did this client make in accomplishing CEDAR treatment goals?
Medical Changes and Psychiatric Changes
Client was approved fro DMH services?
In the past 6 months has the client been psychiatrically hospitalized?
How many times was the person hospitalized in the last 6 months
How many days in total?
In the past 6 months has the client been to a PHP/IOP?
How many times was the person admitted to a PHP/IOP?
How many days in total?
In the past 6 months has the client been to a residential program?
In the past 6 months has the client had a emergency psychiatric evaluations (BEST, ER)?
How many times was the person evaluated in the last 6 months?
Does the client take psychiatric medications?/td>
How many psychiatric medications?
How often are medications taken?
In the past 6 months has the person had any neurological issues (seizures, etc)?
In the past 6 months has the person had any head injuries?
In the past 6 months has the person expereinced any legal issues?
Alcohol Use Rating Scale
Ranking Guidelines

ABSTINENT – Client has not consumed alcohol over the past month.

ALCOHOL USE WITHOUT MEETING DISORDER CRITERIA – Client has consumed alcohol, but there is no evidence of persistent or recurrent problems in social functioning, legal status, role functioning, psychiatric status, or physical problems related to use, and no evidence of recurrent dangerous consumption

ALCOHOL USE DISORDER, MILD Abuse, mild – Client has consumed alcohol, with evidence of 1-3 of the following: alcohol use in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to alcohol use; use of alcohol in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

ALCOHOL USE DISORDER, MODERATE – Client has consumed alcohol, with evidence of 4-5 of the following: alcohol use in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to alcohol use; use of alcohol in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

ALCOHOL USE DISORDER, SEVERE – Client has consumed alcohol, with evidence of 6+ of the following: alcohol use in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to alcohol use; use of alcohol in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

Substance Use Rating Scale
Alcohol Use in the Past Month
Alcohol Use – Worst in the past 6 months
Alcohol Use – Best in the past 6 months
Please rate your confidence in the accuracy of this rating
If low confidence, note reason
Ranking Guidelines

ABSTINENT – Client has not used substances over the past month.

ALCOHOL USE WITHOUT MEETING DISORDER CRITERIA – Client has used drugs, but there is no evidence of persistent or recurrent problems in social functioning, legal status, role functioning, psychiatric status, or physical problems related to use, and no evidence of recurrent dangerous use

ALCOHOL USE DISORDER, MILD – Client has used drugs, with evidence of 1-3 of the following: drug taken in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to drug use; use of drug in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

ALCOHOL USE DISORDER, MODERATE – Client has used drugs, with evidence of 4-5 of the following: drug taken in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to drug use; use of drug in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

ALCOHOL USE DISORDER, SEVERE – Client has used drugs, with evidence of 6+ of the following: drug taken in larger amount than intended; desire or unsuccessful effort to cut back; cravings; substantial time subsumed by obtaining/using/ recovering; use leads to failure to fulfill obligations; social or interpersonal problems relating to drug use; use of drug in hazardous situations; use continued despite awareness of negative consequences; tolerance; withdrawal

Global Functioning: Social Scale
Substance Use in the Past Month
Substance Use – Worst in the past 6 months
Substance Use – Best in the past 6 months
Please rate your confidence in the accuracy of this rating
If low confidence, note reason
Ranking Guidelines

Superior Social/Interpersonal Functioning – Frequently seeks out others and has multiple satisfying interpersonal relationships, including multiple close and casual friends. Is sought out by others because of his or her many positive qualities. Age appropriate involvement in intimate relationships (required).

Above Average Social/Interpersonal Functioning – Interested and involved in a wide range of social and interpersonal activities, including both close and casual friends. Age appropriate involvement in intimate relationships (required). No more than everyday interpersonal problems or concerns (e.g., an occasional argument with spouse, girlfriend/boyfriend, friends, co-workers, or classmates). Able to resolve such conflicts appropriately.

Good Social/Interpersonal Functioning – Mild social impairment is present, but transient and expectable reactions to psychosocial stressors (e.g., after minor arguments with spouse, girlfriend/boyfriend, friends, co-workers, or classmates). Has some meaningful interpersonal relationships with peers (casual and close friends), and/or age appropriate intimate relationships. Infrequent interpersonal conflict with peers.

Mild Problems in Social/Interpersonal Functioning – Mild impairment present that is NOT just expectable reaction to psychosocial stressors (e.g., mild conflicts with peers, co-workers or classmates; difficulty resolving conflicts appropriately). Has some meaningful interpersonal relationships with peers (casual and a few close friends). Some difficulty developing or maintaining age appropriate intimate relationships (e.g., multiple short-term relationships).

Moderate Impairment in Social/Interpersonal Functioning – Moderate impairment present (e.g., evidence of one close friend but limited contact; significant but intermittent conflicts with peers, co-workers or classmates). Moderate difficulty developing age appropriate intimate relationships (e.g., infrequent dating). Occasionally seeks out others, but will respond if invited by others to participate in an activity.

Serious Impairment in Social/Interpersonal Functioning – No close friends or intimate partner, but has some casual social contacts (e.g., acquaintances, school/work friends only). Rarely seeks out others. Occasional combative or verbally argumentative behavior with peers. Beginning to withdraw from family members (e.g., doesn’t initiate conversation with family, but will respond if addressed).

Major Impairment in Social and Interpersonal Funcitioning – Serious impairment in relationships with friends or peers (e.g., very few or no friends, frequent conflicts with friends, or frequently avoids friends). Frequent combative or verbally argumentative behavior with peers. Infrequent contact with family members (e.g., sometimes does not respond to family or avoids family members).

Marginal Ability to Function Socially – Frequently alone and socially isolated. Serious impairment in relationships with all peers, including acquaintances. Few interactions with family members (e.g., often alone in room). Serious impairment in communication with others (e.g., avoids participating in most social activities).

Inability to Function Sociallly – Typically alone and socially isolated. Rarely leaves home. Rarely answers the phone or the door. Rarely participates in interactions with others at home or in other settings (e.g., work, school).

Extreme Social Isolation – No social or family member contact at all. Doesn’t leave home. Refuses to answer the phone or door.

Global Functioning: Role Scale
Current Social Functioning
Social Functioning Lowest in the Past Year
Social Functioning Highest in the Past Year
Please rate your confidence in the accuracy of this rating
Check here if this is a retrospective rating
If low confidence, note reason
Ranking Guidelines


Superior Role Functioning – Independently maintains superior functioning in demanding roles (requires full-time or equivalent). Obtains only superior performance evaluations at competitive work placement. Obtains all A’s in mainstream school. Generates, organizes & completes all homemaking tasks with ease.

Above Average Role Functioning – Independently maintains very good functioning in demanding roles (requires full-time or equivalent). Rarely absent or unable to perform. Obtains good to superior performance evaluations at competitive work placement. Obtains grades in A and B range in all courses in mainstream school. Generates, organizes and completes all homemaking tasks.

Good Role Functioning – Independently maintains good role functioning in demanding roles (requires full-time or equivalent). Occasionally falls behind on tasks BUT always catches up. Obtains satisfactory performance evaluations at competitive work placement. Obtains grades of C and above in mainstream school. Occasional difficulty generating or organizing homemaking tasks. Or Maintains above average performance with minimal support (e.g., tutoring; reduced academic course load at 4-year university; attends community college; may receive additional guidance at work less than 1-2x week). Receives As & Bs, good work/school evaluations, completes all tasks with this level of support.

Mild Problems in Role Functioning – Mildly impaired functioning in demanding roles independently. Frequently behind on tasks or unable to perform. Frequently obtains poor performance evaluations at competitive work placement or grades of Ds or better in mainstream school. Frequent difficulty generating or organizing homemaking tasks. Or Maintains good performance with minimal support (e.g., minimal accommodations in general education classroom; receives additional guidance/support at work 1-2x week). Receives Cs or higher, satisfactory work/school evaluations, and completes most homemaking tasks with this level of support.

Moderate Impairment in Role Functioning – Moderate impairment independently. May receive occasional F in mainstream courses, persistently poor performance evaluations at competitive work placement, may change jobs because of poor performance, persistent difficulty generating or organizing homemaking tasks. Or Requires partial support (some resource or special education courses; receives guidance/support at work 2+ times/week). May require less demanding or part-time jobs and/or some supervision in home environment BUT functions well or adequately given these supports (may fall behind but eventually completes assigned tasks, obtains satisfactory evaluations at work or passing grades in school).

Serious Impairment in Role Functioning -Serious impairment independently. Failing multiple courses in mainstream school, may lose job (e.g. on probation at work), or unable to complete most homemaking tasks independently. Or In entirely special education classes, requires less demanding job/daily support or guidance, may require vocational rehabilitation, and/or some supervision in home environment BUT maintains above average performance – receives As & Bs, good evaluations at work/school, completes all tasks.

Major Impairment in Role – Very serious impairment independently. All Fs in mainstream school or failing out of school. Can’t obtain or hold independent job (e.g., recently fired, multiple short-term jobs in recent past, but actively looking for work or new job anticipated in near future), or unable to complete virtually any homemaking tasks independently. Or Adequate to good functioning with major support. Requires assisted work environment, entirely special education classes, non-public or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment BUT functions adequately given these supports (may fall behind but completes assigned tasks, obtains satisfactory performance evaluations at work or passing grades).

Marginal Ability to Function – Impaired functioning with major support. Requires supported work environment, entirely special education classes, non-public or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment BUT functions poorly despite these supports (persistently behind on tasks, frequently unable to perform, obtains poor performance evaluations at work or fails courses at school).

Inability to Function – Disabled but participates in structured activities. On disability or equivalent non-independent status. Not working for pay, attending classes for grades, or living independently. Spends 5 or more hours a week in structured role-related activities (e.g., actively pursuing/applying for work, residential treatment, volunteering, tutoring, sheltered work programs).

Extreme Role Dysfunction – Severely disabled. On disability or equivalent non-independent status. Not working for pay (e.g., extended unemployment or never entered the workforce AND not looking for work), attending classes for grades, or living independently. Spends fewer than 5 hours a week in structured role-related activities.

Current Role Functioning
Role Functioning Lowest in the Past Year
Role Functioning Highest in the Past Year
Please rate your confidence in the accuracy of this rating
Check here if this is a retrospective rating
If low confidence, note reason

Global Assessment of Functioning
Ranking Guidelines

No Symptoms: 100-91 – Superior functioning in a wide range of activities; Life’s problems never seem to get out of hand; Sought out by others because of his or her many positive qualities

Absent of Minimal Symptoms: 90-81 – Minimal or absent symptoms (e.g. mild anxiety before an examination); Good functioning in all areas and satisfied with life; Interested and involved in a wide range of activities; Socially effective; No more than everyday problems or concerns (e.g. an occasional argument with family members)

Some Transient Symptoms: 80-71 – Mild symptoms are present, but they are transient and expectable reactions to psychosocial stressors (e.g. difficulty concentrating after family argument); Slight impairment in social, work, or school functioning (e.g. temporarily falling behind in school or work)

Some Persistent Mild Symptoms: 70-61 – Mild symptoms are present that are NOT just expectable reactions to psychosocial stressors; e.g. mild or lessened depression and/or mild insomnia); Some persistent difficulty in social, occupational, or school functioning (e.g. occasional truancy, theft within the family, or repeated falling behind in school or work); BUT has some meaningful interpersonal relationships

Moderate Symptoms: 60-51 – Moderate symptoms (e.g. frequent, depressed mood and insomnia and/or moderate ruminating and obsessing; or occasional anxiety attacks; or flat affect and circumstantial speech; or eating problems and below minimum safe weight without depression); Moderate difficulty in social, work, or school functioning (e.g. few friends or conflicts with co-workers)

Some Serious Symptoms of Impairment in Functioning: 50-31 – Serious impairment with work, school, or housework if a housewife/househusband (e.g. unable to keep a job or stay in school, or failing school, or unable to care for family and house); equent problems with the law (e.g. frequent shoplifting, arrests) or occasional combative behavior; Serious impairment in relationships with friends (e.g. very few or no friends, or avoids what friends s/he has); Serious impairment in relationships with family (e.g. frequent fights with family and/or neglects family or has no home); Serious impairment in judgment (including inability to make decisions, confusion, disorientation); Serious impairment in thinking (including constant preoccupation with thoughts, distorted body image, paranoia); Serious impairment in mood (including constant depressed mood plus helplessness and hopelessness, or agitation, or manic mood); Serious impairment due to anxiety (panic attacks, overwhelming anxiety); Other symptoms: some hallucinations, delusions, or severe obsessional rituals; Passive suicidal ideation

Inability to Function in Almost All Areas: 30-21 – Suicidal preoccupation or frank suicidal ideation with preparation; OR behavior considerably influenced by delusions or hallucinations; OR serious impairment in communication (sometimes incoherent, acts grossly inappropriately, or profound stuporous depression); Serious impairment with work, school, or housework if a housewife/househusband (e.g. unable to keep a job or stay in school, or failing school, or unable to care for family and house); Frequent problems with the law (e.g. frequent shoplifting, arrests) or occasional combative behavior; Serious impairment in relationships with friends (e.g. very few or no friends, or avoids what friends s/he has); Serious impairment in relationships with family (e.g. frequent fights with family and/or neglects family or has no home); Serious impairment in judgment (including inability to make decisions, confusion, disorientation); Serious impairment in thinking (including constant preoccupation with thoughts, distorted body image, paranoia); Serious impairment in mood (including constant depressed mood plus helplessness and hopelessness, or agitation, or manic mood); Serious impairment due to anxiety (panic attacks, overwhelming anxiety); Other symptoms: some hallucinations, delusions, or severe obsessional rituals; Passive suicidal ideation

In Some Danger of Hurting Self or Others: 20-11 – Suicide attempts without clear expectation of death (e.g. mild overdose or scratching wrists with people around); Some severe violence or self-mutilating behaviors; Severe manic excitement, or severe agitation and impulsivity; Occasionally fails to maintain minimal personal hygiene (e.g. diarrhea due to laxatives, or smearing feces); Urgent/emergency admission to the present psychiatric hospital; In physical danger due to medical problems (e.g. severe anorexia or bulimia and some spontaneous vomiting or extensive laxative/diuretic/diet pill use, but without serious heart or kidney problems or severe dehydration and disorientation)

In Persistent Danger of Severity HUrting Self and Others – Serious suicidal act with clear expectation of death (e.g. stabbing, shooting, hanging, or serious overdose, with no one present); Frequent severe violence or self-mutilation; Extreme manic excitement, or extreme agitation and impulsivity (e.g. wild screaming and ripping the stuffing out of a bed mattress); Persistent inability to maintain minimal personal hygiene; Urgent/emergency admission to present psychiatric hospital; In acute, severe danger due to medical problems (e.g. severe anorexia or bulimia with heart/kidney problems, or spontaneous vomiting WHENEVER food is ingested, or severe depression with out-of-control diabetes)

Global Assessment of Function – Current
Global Assessment of Functioning Highest in Past Year

SIPS Scores
Ranking Guidelines for Unusual Thought Content/Delusional Ideas

Absent

Questionably Present – “Mind tricks” that are puzzling. Sense that something is different.

Mild – Overly interested in fantasy life. Unusually valued ideas/beliefs. Some superstitions beyond what might be expected by the average person but within cultural norms.

Moderate – Unanticipated mental events that are puzzling, unwilled, but not easily ignored. Experiences seem meaningful because they recur and will not go away. Functions mostly as usual.

Moderately Severe – Sense that ideas/experiences/beliefs may be coming from outside oneself or that they may be real, but doubt remains intact. Distracting, bothersome. May affect functioning.

Severe but Not Psyhchotic – Experiences familiar, anticipated. Doubt can be induced by contrary evidence and others’ opinions. Distressingly real. Affects daily functioning.

Severe and Psychotic – Delusional conviction (with no doubt) at least intermittently. Interferes persistently with thinking, feeling, social relations, and/or behavior.
P1 – Unusual Thought Content/Delusional Ideas
P1 – Frequency
P1 – Date of Symptom Onset
P1 – Date of Symptom Worsening
Ranking Guidelines for Suspiciousness and Persecutory Ideas

Absent

Questionably Present – Wariness.

Mild – Concerns about safety. Hypervigil-ance without clear source of danger.

Moderate – Concerns that people are untrustworthy and/or may harbor ill will. Sense of unease and need for vigilance (often unfocused). Mistrustful. Recurrent (yet unfounded) sense that people might be thinking or saying negative things about person.

Moderately Severe – Thoughts of being the object of negative attention. Sense that people may wish harm. Self-generated skepticism present. Preoccupying, distressing. May affect daily functioning. May appear defensive in response to questioning.

Severe but Not Psyhchotic – Beliefs about danger from hostile intentions of others. Skepticism and perspective can prevail with non-confirming evidence or other’s opinion. Anxious, unsettled. Daily functioning affected. Guarded presentation may diminish information gathered in the interview.

Severe and Psychotic – Delusional paranoid conviction (no doubt) at least intermittently. Frightened, avoidant, watchful. Interferes persistently with thinking, feeling, social relations, and/or behavior.

Ranking Guidelines for Grandiose Ideas
P2 – Suspiciousness and Persecutory Ideas
P2 – Frequency
P2 – Date of Symptom Onset
P2 – Date of Symptom Worsening


Absent

Questionably Present – Private thoughts of being better than others.

Mild – Mostly private thoughts of being talented, understanding, or gifted.

Moderate – Notions of being unusually gifted, powerful or special and have exaggerated expectations. May be expansive but can redirect to the everyday on own.

Moderately Severe – Beliefs of talent, influence, and abilities. Unrealistic goals that may affect plans and functioning, but responsive to other’s concerns and limits.

Severe but Not Psyhchotic – Compelling beliefs of superior intellect, attractiveness, power, or fame. Skepticism and modesty can only be elicited by the efforts of others. Affects functioning.

Severe and Psychotic – Delusions of grandiosity with conviction (no doubt) at least intermittently Interferes persistently with thinking, feeling, social relations, or behavior.

Ranking Guidelines for Perceptual Abnormalities and Hallucinations
P3 – Grandiose Ideas
P3 – Frequency
P3 – Date of Symptom Onset
P3 – Date of Symptom Worsening


Absent

Questionably Present – Minor, but noticeable perceptual sensitivity (e.g. heightened, dulled, distorted, etc.).

Mild – Unformed perceptual experiences/changes that are noticed but not considered to be significant.

Moderate – Recurrent, unformed, images (e.g., shadows, trails, sounds, etc.), illusions, or persistent perceptual distortions that are puzzling and experienced as unusual.

Moderately Severe – Illusions or momentary formed hallucinations that are ultimately recognized as unreal yet can be distracting, curious, unsettling. .May affect functioning.

Severe but Not Psyhchotic – Hallucinations experienced as external to self though skepticism can be induced by others. Mesmerizing, distressing. Affects daily functioning.

Severe and Psychotic – Hallucinations perceived as real and distinct from the person’s thoughts. Skepticism cannot be induced. Captures attention, frightening. Interferes persistently with thinking, feeling, social relations and/or behavior.

Ranking Guidelines for Disorganized Communication
P4 – Perceptual Abnormalities and Hallucinations
P4 – Frequency
P4 – Date of Symptom Onset
P4 – Date of Symptom Worsening


Absent

Questionably Present – Occasional word or phrase doesn’t make sense.

Mild – Speech that is slightly vague, muddled, overelaborate or stereotyped.

Moderate – Incorrect words, irrelevant topics. Goes off track, but redirects on own.

Moderately Severe – Speech is circumstantial (i.e. eventually getting to the point). Difficulty directing sentences toward a goal. Sudden pauses. Can be redirected with occasional questions and structuring.

Severe but Not Psyhchotic – Speech tangential (i.e. never getting to the point). Some loosening of associations or blocking. Can reorient briefly with frequent prompts or questions.

Severe and Psychotic – Communication persistently loose, irrelevant, or blocked and unintelligible when under minimal pressure or when the content of the communication is complex. Not responsive to structuring of the interview.

P5 – Disorganized Communication
P5 – Frequency
P5 – Date of Symptom Onset
P5 – Date of Symptom Worsening
Is there a family history of severe mental illness?

Psychosis Risk Diagnostic Criteria
Rule In current Psychotic Syndrome

Rule In remission from Psychotic Syndrome
Are any of the SOPS P1-P5 Scales scored 6, or have they ever been?
If Yes to 1, are the symptoms seriously disorganizing or dangerous, or were they ever?
If Yes to 1, did the symptoms occur for at least one hour per day at an average frequency of four days per week over one month?
Date when criteria achieved

Was the subject previously diagnosed on the SOPS with a Psychotic Syndrome?
Does the subject currently score less than 6 on each of the SOPS P1-P5 Scales?
If Yes to 2, has each of the SOPS P1-P5 symptoms scored less than 6 for at least 4 consecutive weeks?
Indicate date when criteria for remission was achieved

Brief Intermittent Psychotic Symptom Psychosis-Risk Syndrome

Rule In Current BIPS

Rule In Remission For BIPS
Are any of the SOPS P1-P5 Scales scored 6?
If Yes to 1, have the symptoms reached a psychotic level of intensity in the past three months?
If Yes to 1 and 2, are the symptoms currently present for at least several minutes per day at a frequency of at least once per month?
Are all otherwise qualifying symptoms better explained by another DSM-5 disorder?
Date when criteria achieved

Was the subject previously diagnosed on the SOPS with a BIPS?
Does the subject currently score less than 6 on each of the SOPS P1-P5 Scales?
If Yes to 2, has each of the SOPS P1-P5 symptoms scored less than 6 for at least 4 consecutive weeks?
Date when criteria for remission was achieved

Attenuated Positive Symptom Psychosis-Risk Syndrome
Rule In Current APSS

Rule In Remission from APSS
Are any of the SOPS P1-P5 Scales scored 3-5?
If Yes to 1, have any of these symptoms begun within the past year or do any currently rate one or more scale points higher compared to 12 months ago?
If Yes to 1 and 2, have the symptoms occurred at an average frequency of at least once per week in the past month?
Are all otherwise qualifying symptoms better explained by another DSM-5 disorder?
Date when criteria achieved
Was the subject previously diagnosed on the SOPS with an APSP?
Does the subject currently score less than 3 on each of the SOPS P1-P5 Scales?
If Yes to 1 and 2, has each of the SOPS P1-P5 symptoms scored less than 3 for at least 4 consecutive weeks?
Date when criteria for remission achieved

Modified Attenuated Positive Symptom Psychosis-Risk Syndrome
Rule In Current MAPSS

Rule Remission from MAPSS
Are any of the SOPS P1-P5 Scales scored 3-5?
If Yes to 1, have the symptoms occurred at an average frequency of at least twice per month in the past three months?
Does not meet criteria for B. Attenuated Positive Symptom Psychosis-Risk Syndrome.
Are all otherwise qualifying symptoms better explained by another DSM-5 disorder?
Date when criteria achieved
Was the subject previously diagnosed on the SOPS with MAPSS?
In the past month, does the subject currently score less than 3 on each of the SOPS P1-P5 Scales?
Date when remission criteria was achieved

Summary of Diagnosis

Psychotic Syndrome Brief Intermittent Psychotic Symptom Psychosis-Risk Syndrome Attenuated Positive Symptom Psychosis-Risk Syndrome Modified Attenuated Positive Symptom Psychosis-Risk Syndrome Other DSM-5 Disorders

Ranking Guidelines for Current Clinical Risk


0 – N/A

1 – In Remission – Criteria are in Remission as per PDC above

2 – Symptomatic – Previously met Psychosis Risk State criteria, continues to experience symptoms, but no new or worsening symptoms in the last year

3 – Psychosis Risk State – Meets or continues to meet criteria as rated on the PRS above, has experienced new/worsening symptoms

4 – Previously Fully Psychotic – In remission. All P symptoms <3

5 – Previously Fully Psychotic – Symptomatic but attenuated. At least one P symptom rated as 3-5

6 – Psychotic – At least one P symptom rated as a 6

Current Clinical State
Did the client convert to full psychosis since their last CEDAR assessment

Screening for Risk of Harm to Self and Others
Suicide

Lifetime – Have you ever wished that you were dead or that you would stop existing? Past Month – Have you ever wished that you were dead or that you would stop existing? Lifetime – Have you had any thoughts of killing yourself? Past Month – Have you had any thoughts of killing yourself?

If no to all 1 and 2, circle “no” to all below and proceed to the next section

Lifetime – Have you thought about how you might kill yourself? Past Month – Have you thought about how you might kill yourself? Lifetime – Do you ever do anything hoping that it would result in you dying? (e.g., cross the street without looking) Past Month – Do you ever do anything hoping that it would result in you dying? (e.g., cross the street without looking) Lifetime – Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan? Past Month – Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan? Lifetime – Have you ever done anything in preparation to do anything to end your life (e.g., wrote a suicide note, prepared means to end your life)? Past Month – Have you ever done anything in preparation to do anything to end your life (e.g., wrote a suicide note, prepared means to end your life)? Lifetime – Have you tried to kill yourself? How many times? When was the last time? Past Month – Have you tried to kill yourself? How many times? When was the last time? Recent Attempts Severity of Risk

Self-Injury/Non-Suicidal Self-Injury
Lifetime – Have you ever had thoughts or urges to injure yourself in any way?
Past Month – Have you ever had thoughts or urges to injure yourself in any way?
Lifetime – Have you ever done anything intentionally to injure yourself (e.g., cutting, burning, starvation/exercise for purpose of feeling pain)?
Past Month – Have you ever done anything intentionally to injure yourself (e.g., cutting, burning, starvation/exercise for purpose of feeling pain)?
Lifetime – Have you ever done other kinds of risky things without caring about harm to yourself (e.g., risky sexual behavior, running away from home)?
Past Month – Have you ever done other kinds of risky things without caring about harm to yourself (e.g., risky sexual behavior, running away from home)?
Recent Engagement in NSSI
Severity of NSSI

Harm to Others
Lifetime – Do you ever notice yourself thinking about or imagining hurting other people?
Past Month – Do you ever notice yourself thinking about or imagining hurting other people?
Lifetime – Have you ever yelled at people? Have you threatened them? What kinds of things have you said?
Past Month – Have you ever yelled at people? Have you threatened them? What kinds of things have you said?
Lifetime – Have you ever physically injured anyone?
Past Month – Have you ever physically injured anyone?
Recent Harm to Others
Likelihood of Harming Others

Diagnostic Check List
Psychotic Disorders
Does the client have a psychotic disorder
Schizophrenia
Schizoaffective Disorder
Other Psychotic Disorder
Does the client have an Affective Disorder
Major Depressive Disorder
Severity of Depression
Dysthymic Disorder
Bipolar I Disorder
Bipolar II Disorder
Mood Disorder with Psychotic Features
Other Affective Disorder
Does the client have a nuerodevelopmental disorder
ADHD
Autism Spectrum Disorder
Communiation or Learning Disorder
Other Developmental Disorder
Does the client have a substance use disorder
Alcohol Use Disorder
Cannabis Use Disorder
Other Substance Use Disorder
Does the client have an anxiety disorder
Generalized Anxiety Disorder
Panic Disorder
Specific Phobia
Obsessive Compulsive Disorder
Social Anxiety Disorder
Other Anxiety Disorder
Does the client have a trauma/stressor related disorder
PTSD
Other Trauma/Stressor Related Disorder

Thank you