1. Reasons for referral: (quote referring person's own words)
2. Referral source: (specify clinic/institution, person/clinician, profession)
__ patient (self-referred),
__ family, migrant and refugee health services,
__ medical specialist
__ social worker
__ emergency ward
__ pediatric ward
3. How did the referral source learn about the existence of the Cultural Consultation Service (CCS)?
4. Does the referral source know a particular person associated with the CCS?
5. How was the suggestion for referral received by the patient/family?
6. How did the triage process take place? (List all applicable)
__ From within institution? (ER, OPD, Screening clinic, Staff member, etc.)
__ Call by patient/family to psychiatry general intake?
__ Call by referring person to general psychiatry intake?
__ Call by patient/family to a member of the CCS?
__ Call by referring person to the CCS?
B. Patient Identification
- country of origin
- languages spoken, primary language spoken at home
- parent's occupation, current and past
- citizenship & immigration status
- length of stay in Canada
- moves in Canada
- who lives at home
- children's school and grade
- language of instruction at school
- eligibility certificate option
C. Presenting Problem
1. Describe in the patient's/family's own words.
2. Note duration
D. Setting of Evaluation
1. Who was present at the assessment interviews?
Family members (list all present)
Team members (list all present)
If more than one team member present, what were their roles in the interview?
Culture brokers or interpreter:
__ family member acting as interpreter
__ professional interpreter
__ other (specify) _____________________________________)
2. What was the physical setting of the assessment interview?
Use of one-way mirror, video, recording, etc.
E. History of present illness
- Nature of problem
- Symptoms described
- Evolution of problem
- Level of function at home, work, with friends, extended family, community
- Previous help-seeking for problem
- Did the patient/family consult a medical specialist for the present problem?
- Did the patient/family consult alternative resources for the present problem?
F. Past Medical History
- major illnesses, injuries, disabilities
- drug or alcohol use
G. Psychiatric History
- Previous involvement with psychiatry, psychologist, other mental health professional, social worker, school counselor
- What was the problem at that time?
- What formulation of the problem was offered to the patient/family (e.g. DSM- IV, other)?
- Previous treatments (medication, hospitalization, psychotherapy, family therapy, other interventions.)
- Was the treatment successful or not?
H. Family History
- Identify people living together in household
- Identify any nuclear family members not living together (e.g., left behind in country of origin)
- Did any family member have a mental health difficulty?
- How was this difficulty managed/treated?
- Did anyone have a problem similar to the identified patient's?
- Relevant family events and stresses (e.g. death, loss or separation, chronic illness or disability, imprisonment or threat of imprisonment, harassment)
Patient's Family: Mother's/Father's family
- Where was mother/father born?
- birth order in family
- number of siblings
- What was mother's/father's relationship with her/his father like?
- … with her/his mother?
- Is there a history of migration in mother's/father's family?
- Trauma due to political violence?
- A history of parent child separations?
Marital History (if applicable)
- How did the couple meet?
- How old were they?
- Are they married?
- Was the marriage arranged?
- How did both families accept the union?
- Was either partner previously married?
- Does either partner have other children?
Children's History (if applicable)
- How were the children's names chosen?
- What do their names mean?
- Are there other children in the family whom they are responsible for? (e.g. fostered, adopted)
- How are they related to the couple?
- Were there children born since their arrival to Canada?
- Does the child have a filial or emotional bond with adults other than the parents? (e.g. maternal uncle in some matrilineal cultures; mid-wife, etc.)
- What are the couple's countries of origin?
- When did they leave?
- Why did they leave?
- Who decided to leave?
- What was their migration route to Canada?
- Did they live in a refugee camp? For how long?
- What was their perception of their migration experience?
- Were family members left behind?
- Were their children left behind and with whom?
- Did their children travel separately?
- Were they accompanied?
- Are there plans to reunite with family members who stayed behind?
I. Social & Developmental History
J. Family Assessment
- pertinent mental status of family members
- communication issues
- instrumental functioning
- problem solving skills
K. Mental Status Exam
L. Psychological Testing
M. Other Investigations
- Laboratory tests
N. Diagnostic formulation at assessment (DSM Axes I-IV)
A. Cultural Identity
1. Cultural reference group(s)
- ethnocultural and religious groups with which the patient self-identifies
- other ethnocultural background the patient may not explicitly identify with
- father's ethnocultural and religious background
- mother's ethnocultural and religious background
- Languages spoken while growing up
- Language(s) currently spoken between patient and family
- Language(s) spoken at work
- Language(s) spoken in health care settings
- Language(s) in which patient literate?
3. Cultural factors in development
- involvement with siblings,
- involvement with peers
- social activities
4. Involvement with culture of origin
- Contact with family or friends in country of origin
- Involvement with community organizations
- Does patient attend a group with peers of his culture of origin (e.g. religious organization or leisure setting)?
- Does patient have friends from his culture of origin ?
- Does patient socialize with extended family members?
- What is patient's perception of his culture of origin?
5. Involvement with host culture
- Does patient attend a group with peers of host culture (e.g. work, religion, leisure etc)?
- Does patient have host culture friends?
- What is patient's perception of host culture? Has s/he experienced racism?
B. Cultural Explanations of the Illness
1. Predominant idioms of distress and illness categories
2. Meaning and severity of symptoms in relation to cultural norms
- of cultures of origin
- of host culture
3. Perceived causes and explanatory models
- prototypes (self, other, media)
- expected outcome
4. Help-seeking experiences and plans
- with the formal health care system
- with traditional healers and alternative services
C. Cultural Factors Related to Psychosocial Environment & Levels of Functioning
1. Social stressors
- Current political situation in country of origin and in host country
- What does individual/family feel is the worst stressor?
- Taking into account cultural norms and social and family structure, what unique stressors can the clinician identify?
2. Social supports
- What are the most important past and current sources of support for the individual/family?
3. Levels of functioning and disability
- at home
- in extended family
- community of origin
- host community
- at work
- with peers
D. Cultural Elements of the Clinician-Patient Relationship at Assessment
- What is the clinician's ethnocultural background ?
- Does the clinician speak the patient's language?
- Does the clinician have specific knowledge about the patient's culture?
- What is the history of the relationships between the patient's culture of origin and the clinicians' (e.g. colonization, sociopolitical conflict, local history and conflict, racism)?
- Was this issue addressed or not?
- Were there any value conflicts between the clinician and the patient?
E. Overall Cultural Assessment
- Go back over each category above and draw out implications for the case.
- What role do social and cultural factors play in this patient's problems and their potential solutions?
- Did the migration history play a role in the patient's problems and their potential solution?
- Did cultural factors change the formulation or /assessment of the…
- (Please check all that are applicable and describe)
__ judgement of illness severity
__ rating of level of functioning
__ rating of level of social supports
__ rating of level of stressors
__ treatment plan
__ therapeutic alliance
__ method of communication with client or family
__ involvement of others in treatment
__ traditional or alternative healers
Please check all modalities in the recommended treatment plan for this case.
A. Therapeutic Modalities
__ psychotherapy ( individual, group, family, play therapy, art therapy, other)
__ Was an interpreter involved? (if yes go to interpreter questionnaire)
__ Was a time frame given in advance (e.g. short or long term)?
__ internal (e.g. prayer, home shrine)
__ provision of psychological expertise
__ liaison with lawyer
__ provision of supportive letter
__ appearance at court
__ Referral to key member of person's cultural community
__ Referral to community aid organizations
__ Reinsertion into community of origin, host community, other communities
Where was treatment sought:
__ country of origin
__ host country
__ transnational network?
Was traditional healing provided by person's culture of origin or another cultural tradition?