Refer to the example presented in the content section of the course to conduct an intake assessment on a friend or classmate. Develop a problem and a complete history of the client. Use the attached a

Intake Assessment Form

Client Name _______________________________________ D.O.B. __________________

Unit # __________ Date of Assessment__________________________________________

1. PRESENTING PROBLEM (Functional impairment..(What is it impairing, symptoms, background) Example john is a 16 year old boy living with his single mom and currently addicted to alcohol. Next two sentences write 2-3 sentences to describe the client situation. Example He is currently not attending school and his mother indicates she cannot manage him at present. The boy father is not in the picture and mother works 2 jobs to support the daughter and self.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES (add in a local service)

AGENCY/PERSON PHONE SERVICE DATE

3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS (How is the family, social functioning, support, legal, education, occupation, finances, etc in these areas?) What does that look like?

FAMILY

SOCIAL

SUPPORT

LEGAL

EDUCATION

OCCUPATION

FINANCES

PSYCHOSOCIAL & ENVIRONMENTAL PROBLEMS

4. CURRENT MEDICAL CONDITIONS (Does the client have any other medical conditions such as depression, ADHD, etc?)

CONDITION PHYSICIAN TREATMENT

5. PREGNANT ( ) YES ( ) NO

RECEIVING PRENATAL CARE? ( ) YES ( ) NO

6. PRIMARY CARE PHYSICIAN (Who is the physician and location

7. CURRENT MEDICATIONS (List all clients current medications)

NAME /DOSAGE PRESCRIBED BY CONDITION

SIDE EFFECTS ____________________________________________________________________________________

MEDICATION ALLERGIES ____________________________________________________________________________________

7. RELATIONSHIP RISK FACTORS;

IS CLIENT SAFE AT HOME? ( ) YES ( ) NO

DOES CLIENT FEEL THREATENED IN ANYWAY? ( ) YES ( ) NO

IF YES DESCRIBE ____________________________________________________________________________________

HAS CLIENT BEEN ABUSED IN ANY WAY ( ) YES ( ) NO

IF YES CHECK ALL THAT APPLY

( ) PHYSICAL ( ) EMOTIONAL ( ) SEXUAL

RELATIONSHIP OF PERPETRATOR TO CLIENT ___________________________________________________________________________________

ANY LEGAL ACTION TAKEN? ___________________________________________________________________________________

DOES CLIENT HAVE A SAFETY PLAN? ( ) YES ( ) NO

NEEDS SHELTER ( ) YES ( ) NO NEEDS PROTECTION FROM ABUSE ORDER ( ) YES ( ) NO

8. SUICIDE/HOMICIDE EVALUATION

CLIENT'S SELF RATING OF SUICIDE RISK ____________

CLIENT'S SELF RATING OF BECOMING VIOLENT __________

CLIENT'S SELF-RATING OF HOMICIDE RISK __________

(1-NONE 2 – SLIGHT 3 – MODERATE 4 – EXTREME/IMMEDIATE)

9. MENTAL STATUS EXAM (Just check client mental condition. What does the client appearance look like etc…does not need any additional information)

_________________________________________________________________________________________________________________

APPEARANCE ( ) Age appropriate ( ) Well groomed ( ) disheveled/unkempt ( ) bizarre ( ) other

ORIENTATION ( ) Person ( ) Place ( ) Time ( ) Situation

BEHAVIOR/ EYE ( ) Good ( ) Limited ( ) Avoidant ( ) None ( ) Relaxed/calm ( ) Restless

CONTACT ( ) Rigid ( ) Agitated ( ) slumped posture ( ) Tense ( ) Tics ( ) Tremors

MOTOR ACTIVITY ( ) Mannerisms ( ) Motor retardation ( ) Catatonic behavior

MANNER ( ) Appropriate ( ) Trusting ( ) Cooperative ( ) Inappropriate ( ) Withdrawn

( ) Seductive ( ) Playful ( ) Evasive ( ) Guarded ( ) Sullen ( ) Passive

( ) Defensive ( ) Hostile ( ) Manic ( ) Demanding ( ) Inappropriate boundaries

SPEECH ( ) Normal ( ) Incoherent ( ) Pressured ( ) Too detailed ( ) Slurred ( ) slowed

( ) Impoverished ( ) Halting ( ) Neologisms ( ) Neurological language disturbances

MOOD ( ) Appropriate ( ) Depressed ( ) Irritable ( ) Anxious ( ) Euphoric ( ) Fatigued

( ) Angry ( ) Expansive

AFFECT ( ) Broad ( ) Tearful ( ) Blunted ( ) Constricted ( ) Flat ( ) Labile ( ) Excited

( ) Anhedonic

SLEEP ( ) Good ( ) Fair ( ) Poor ( ) Increased ( ) Decreased ( ) Initial insomnia

( ) Middle insomnia ( ) Terminal Insomnia

APPETITE ( ) Good ( ) Fair ( ) Poor ( ) Increased ( ) Decreased ( ) Weight gain

( ) Weight loss

THOUGHT PROCESS ( ) Logical and well organized ( ) Illogical ( ) Flight of ideas ( ) Circumstantial

( ) Loose Associations ( ) Rambling ( ) Obsessive ( ) Blocking ( ) Tangential

( ) Spontaneous ( ) Perseverative ( ) Distractible

THOUGHT CONTENT ( ) Delusions ( ) Paranoid delusions ( ) Distortions ( ) Thought withdrawal

( ) Thought insertion ( ) Thought broadcast ( ) Magical thinking

( ) Somatic delusions ( ) Ideas of reference ( ) Delusional guilt

( ) Grandiose delusions ( ) Nihilistic delusions ( ) Ideas of inference

PERCEPTION/HALLUCINATIONS ( ) Illusions ( ) Hallucinations ( ) Depersonalization ( ) Derealization

SUICIDE RISK ( ) None ( ) Slight ( ) Moderate ( ) Significant ( ) Extreme

( ) No Plan ( ) Plan (describe _________________________________________________________________________________________________________

________________________________________________________________________________

VIOLENCE RISK ( ) None ( ) Slight ( ) Moderate ( ) Significant ( ) Extreme

( ) No Plan ( ) Plan (describe _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

9. MENTAL STATUS EXAM cont.

____________________________________________________________________________

JUDGEMENT ( ) Intact ( ) Age appropriate ( ) Impulsive ( ) Immature ( )

( ) Impaired ( ) Mile ( ) Moderate ( ) Severe

INSIGHT ( ) Intact ( ) Limited ( ) very limited ( ) Fair ( ) None

( ) Aware if current disorder ( ) Understands personal role in problems

SENSORIUM ( ) Alert ( ) Drowsy ( ) Stupor ( ) Obtundation ( ) Coma

MEMORY ( ) Intact ( ) Impaired ( ) Immediate recall ( ) Remote ( ) Amnesia

Type of amnesia _________________________________________________________________________________________________________

INTELLIGENCE ( ) Average ( ) Above average ( ) Below average ( ) Unable to establish

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INTERVIEWER SUMMARY OF FINDINGS ( add details where appropriate

10. SUBSTANCE USE/ABUSE

TYPE AMOUNT HOW TAKEN DURATION FREQUENCY DATE OF LAST

USED USE

_____________________________________________________________________________________________

TOBACCO _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

ALCOHOL_________________________________________________________________________________________________________________________________________________________________________________________________________

ILLICIT DRUGS _________________________________________________________________________________________________________

_________________________________________________________________________________________________________
PRESCRIPTION DRUGS _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

OTC DRUGS _________________________________________________________________________________________________________

OTHER _________________________________________________________________________________________________________

EXPERIENCING: (Check off)

WITHDRAWAL ( ) YES ( ) NO

BLACKOUTS ( ) YES ( ) NO

HALLUCINATIONS ( ) YES ( ) NO

VOMITING ( ) YES ( ) NO

SEVERE DEPRESSION ( ) YES ( ) NO

DTS AND SHAKING ( ) YES ( ) NO

SEIZURES ( ) YES ( ) NO

OTHER ( ) YES ( ) NO DESCRIBE _____________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

PATTERNS OF USE

USES MORE UNDER STRESS ( ) YES ( ) NO

CONTINUES USE WHEN OTHERS HAVE STOPPED ( ) YES ( ) NO

HAS LIED ABOUT CONSUMPTION ( ) YES ( ) NO

HAS TRIED TO AVOID OTHERS WHILE USING ( ) YES ( ) NO

HAS BEEN DRUNK/HIGH FOR SEVERAL DAYS AT A TIME ( ) YES ( ) NO

NEGLECTS OBLIGATIONS WHEN USING ( ) YES ( ) NO

USUALLY USES MORE THAN INTENDED ( ) YES ( ) NO

NEEDS TO INCREASE USE TO BECOME INTOXICATED ( ) YES ( ) NO

HAS TRIED TO IDE CONSUMPTION ( ) YES ( ) NO

SOMETIMES USES BEFORE NOON ( ) YES ( ) NO

CANNOT LIMIT USE ONCE BEGUN ( ) YES ( ) NO

FAILED TO KEEP PROMISES TO REDUCE USE ( ) YES ( ) NO

DESCRIBE ATTEMPTS TO STOP

DESCRIBE CIRCUMSTANCES THAT USUALLY LEAD TO RELAPSE

IS CLIENT INVOLVED IN AA/NA? ( ) YES ( ) NO _____________________________________________________________________________________________

11. CLIENT REQUESTS, GOALS, EXPECTATIONS( These are when you are working with the client to develop these goals and expectations) Follow smart goals or map goals as well.

12. CLINICAL SUMMARY (PULL TOGETHER INFORMATION YOU HAVE COLLECTED AND SUMMARIZE, IDENTIFYING POSSIBLE RELATIONSHIPS, CONDITIONS AND CAUSES THAT MAY HAVE LED TO CURRENT SITUATION) Use your subjective language.

13. IMPRESSIONS

14. RECOMMENDATIONS (Write your recommendations and say what they are for an example Recommend 3 weeks intensive impatient treatment for detox, followed by NA meeting, 90 meetings, 90 days for supporting and remain clean, family and individual counseling to develop better family relationships and John’s self-esteem. Recommend John return to school at the end of inpatient treatment to maintain his academic achievement.