This is the final written assignment in this course. Throughout the course, you should work to infuse information about your couple and identified patient (Jasmine) in each section. This template is

FAMILY INTAKE FORM

1. Name: __Dilan Robertson

_________________________________ DOB: __10-18-97___________________

Address: __1234 Folsom St. Beaumont Texas, 77703 ____________________________________________________________________

Marital Status:__never married _______________________________ Male/Female: ____________________

Phone: H(____) _____________W(____)____________________C(_409___)___555-5889 _______________

Emergency contact (name and phone #) _Margret Robertson 409- 555-6959 ____________________________________________

1. Name: __Jasmine Bailey _________________________________DOB:__08/30/1990___________________

Address: ___5678 Lucas Dr. Beaumont Texas, 77706 ___________________________________________________________________

Marital Status:___never married______________________________ Male/Female:

____________________

Phone: H(____)_____________W(____)____________________C(409_ )__555-7458 Barbra Jackson _409-555-2356 _______________ Emergency contact (name and phone #)_____________________________________________

BIOPSYCHOSOCIAL

Biological Component

Right now, we’re going to assess the current health history and status of each family member.

1. Are there any current illnesses? IP’s reported no current or past medical problems

2. Are there any physical disabilities? None reported

3. What medications and dosage amount are being taken by the both of you? No reported medications at this time

4. Are you currently under treatment from a medical professional and are you willing to sign a release of information? Non-Applicable

5. Are there any current health conditions of extended family members that could be a stressor for your family? Both report no stressors

Right now, we’re going to assess the past health history and health-related behaviors for each family member.

1. What previous experiences has any family member had with prior health conditions of family members? Jasmine reports that her grandmother suffers with diabetes’s and high bold pressure. Dilan reports his mother suffers with high blood pressure.

2. What are your diet and food consumption practices? Dilan and Jasmine reports that they definitely could eat healthier. Jasmine also reports that she likes to snacks at night, which she acknowledges was not healthy.

3. How about sleep and the quality of sleep for each of you? Jasmine reported that they do not have problems with sleeping or falling asleep, however Dilan reports that he has had some problems with fallen to sleep in the past 30 days.

4. Please share how often you exercise? Jasmine reports that she has recently joined a fitness club to get more toned and loose her baby bump. Dilan reports that he does not have an exercise regimen at this time.

5. Have you or any family member currently or formerly been addicted to or overused any substance? Both report currently using marijuana alcohol. Jasmine reports family history of substance use. Jasmine reports that she was addicted to cocaine 6 six years ago and since been clean 2014. Jasmine also reports that she has been treated for substance abuse in the past and has experimented with various drugs and alcohol.

Psychological Component (Read the article and create questions underneath each transition statement in the format indicated above)

Right now, we’re going to assess the personality for each family member.

1. Tell us about your strengths, skills, abilities, and positive traits. Jasmine stated that she is very outgoing, motivated, goal oriented, good mother, and ambitious. Dilan reports that he is kind, loving, shy, easy to get along with, and a people person.

2. I believe in the importance of (complete the sentence) __Family!!!! stated by both____

3. Do you fear the worst & avoid mistakes? Jasmine stated that she definitely fears the worse and often try to avoid making the same mistakes. Dilan however stated that he has always been a pretty optimistic person and just live life to the fullest not worrying about mistakes or avoiding them. “If they happen, they happen, then I’ll deal with it then”.

4. Are you a person that worry’s a lot? Dilan stated that he does not worry a lot, however Jasmine states that she worries about a lot of things in her life such as raising her daughter right because she made so many mistakes in the beginning.

5. I have a low or high opinion of self. Dilan states that in the beginning of their relationship his opinion was high of himself, but in recent months he feels low because of his non-accomplishments in life and that it did not help when Jasmine constantly reminding him of his character defects. Jasmine reports that she also has had high opinion of herself, but in recent months it has decreased due to her constant self-attacks and beating herself up about her anger outburst.

Next, we’re going to assess the mood/affect for each family member.

1. Are you easily angered? Jasmine reports that she has uncontrollable anger outburst over little things that will set her off. Dilan reports the opposite and states that he is a pretty calm person and it takes a lot for him to become angry.

2. I get easily irritated, yes or no. Jasmine states that she is easily irritated and agitated over the smallest things. Dilan reports he becomes irritated at Jasmine’s constant outburst and removing himself from the hostile situation.

3. I feel others emotions, yes or no. Jasmine reports that she is a caring person and will give the shirt off of her back, but cannot tolerate a lot of unacceptable behavior from no one. Dilan states that he like to think of himself as caring but knows that he can be selfish at times.

4. I’m often in a bad mood or good mood. Jasmine stated that for the most part she is in a good mood, until her anger or irritation is triggered. Dilan states that he is pretty much always in a good mood.

5. Are you normally comfortable or uncomfortable around others? Both stated that they don’t like to be around a lot of people unless it is family, but typically if in public depending on the environment they are comfortable.

Right now, we’re going to assess the mental health conditions of for each family member.

1. Have you ever received childhood mental health services or been told you need mental health services? Dilan reports no mental health condition in lifetime. Jasmine reports that she was diagnosed in 2018 after having her first child with post-partum depression and was placed on medication that she did not take. Jasmine stated that she recently had a miscarriage and feels that she may be having post-partum again because of her irritability she sometimes has with her daughter and Dilan.

2. Is there any history of family mental health or was a family member depressed or mentally ill? No family history of mental illness with either of them.

3. Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior? Dilan stated “No”, however Jasmine reports in 2018 during her post-partum she felt certain people was trying to take her baby away from her and noted that this action motivated her to get her act together.

4. Do you frequently have difficulties paying attention, concentrating, getting really upset at little things or what people have told you are little, getting along with others without arguing or fighting, or Remembering things? Dilan “No”, Jasmine reports yes here in the past recent months she finds herself getting easily upset or anger over little stuff.

5. Have you ever had suicidal ideations and or attempts at suicide and if so, would you like assistance with your mental health? Dilan “No”, Jasmine states that she has not had any suicidal ideations or attempts in the past 30 days, but yes in a lifetime. Jasmine also stated that she would agree to further testing and a psych-evaluation and she signed consent and was referred to MHMR and Family Services for psycho-therapy counseling.

Now for your degree of hope of for each family member. Please describe it for me.

1. What would you say your outlook on life is? Both say that they have a good outlook on life

2. Describe what fears you may or may not have about your future? Jasmine reports fear losing Dilan because she is mean to him and take a lot of her frustrations out on him. Dilan stated that he fears Jasmine will leave him because he may not be the man she wants him to be.

3. What is you’re a sense of direction and the ability to see a light at the end of the tunnel? Dilan states that he tries to see the light at the end of the tunnel in every situation. Jasmine stated that she is pretty goal-oriented and eventually sees the light at the end of the tunnel, only after she has calmed down or talked to someone.

4. What is a sense of giving and receiving love? Jasmine reports that for her this is one of the most important things in life for her and is a game changer. She reports that she has a lot of love to give, but also wants it to be reciprocated. Dilan stated that he sometimes struggles with giving and receiving love because emotions and affections were not often displayed in his home and that he can be pretty selfish at times.

5. Do you have goal-directed energy and/or plans to accomplish goals? Dilan reports that this is a character defect that he knows he possess that he is not goal oriented or motivated to accomplish goals which has created problems in his relationship. Jasmine reports that she is very goal-oriented and once goal has been set she usually accomplishes more times than not.

For the final portion of the psychological component, please address the stressors of each family member.

1. Did you often feel no one in your family loved you or thought you were important or special or your family didn’t look out for each other, feel close to each other, or support each other? Dilan reports that even though love was not usually expressed in the home he and his sisters knew that their parents loved them and that he has never felt alone or abandoned by his family, in fact Dilan reports quite the opposite that his family are enablers. Jasmine reports that all her life she has felt estranged from certain family members including her siblings. Jasmine reports having close relations with her younger sister, aunt, and grandmother.

2. How frequently do you find yourself experiencing such problems as headaches, problems going to sleep or staying asleep, unexplained muscle pain, jaw pain, uncontrolled anger, and frustration? Dilan reports not often and Jasmine reports experiencing uncontrolled anger and frustrations often.

3. In the last month, how often have you been upset because of something that happened unexpectedly? Dilan reports out of 30 days maybe twice and Jasmine reports maybe 4x out of the past 30 days.

4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? Both report that they have had increased amount issues or concerns pilling up such as them looking for suitable housing and living arrangements.

5. In the last month, how often have you felt confident about your ability to handle your personal problems? Both report that they have felt confident

Social Component (Read the article and create the transition statement and questions in the format indicated above)

Now were going to assess the Social Component for each of you. Explore family, intimate relationships, friends, colleagues, community, sociopolitical environment, and culture.

1. Who do you turn to for support inside and outside of the family; Is there any community involvement? Dilan reports that he turns to his parents and sister for support only and Jasmine reports that she turns to her aunt mostly and that she has no one outside of family that she trusts.

2. Who would you consider to be family? Dilan reports that he considers of course his parents and sister, and that he has developed a special bond with Jasmin’s aunt who is very supportive of Jasmine. Jasmine reports that she considers everyone blood related her family and that she had developed relationships in church with the women and consider them as family.

3. Who are you most likely to turn to in time of need that you share your most important emotions and thoughts? Both said each other only

4. How often do you associate with friends, types of information shared with friends, and is it reciprocated; Are there any current political policies that shape your decision making or contribute to any presenting problems? Dilan stated that he has one childhood friend that he associates with and share information about everything including family and his relationship with Jasmine. Jasmine reports that when she changed her lifestyle she lost a lot of friends and only considers her baby sister a true friend that she tells everything too.

5. While in school did you have a lot of absenteeism; reprimands, suspensions, or promotions on the job? Both acknowledge that they had all the above and were not good students.

6. Tell me about your country of origin, ethnic identification, and religious values/beliefs. Both identified with being African American and country of origin is United States. However, Dilan reports that he does not have a strong religious background, but believes in God. Jasmines stated the same on the background, and also states in her older years she has come to find spirituality and God.

Spiritual Component (Read the article and create the transition statement and questions in the format indicated above)

Next were going to assess Spirituality and any spiritual practices, if any.

1. Do you participate in any specific religious organization or any activities that help you have a connection with a higher power, society, or nature? Both report that they are not at this time affiliated with any organizations or church, however Jasmine states that she wants to get back into church.

2. Whom/What do you feel you get your strength? How do you connect with society or humanity? Both say that they get their strength from God and both say they have no connections in the community, however Jasmine stated that when she was in church she volunteered a lot in the outreach program feed and clothing the homeless.

3. Do you believe “Everything is good” or “Everything happens for a reason”. Both stated that they feel “Everything happens for a reason” and Both stated that “Everything is not good”.

4. What are some centered or mindful practices that the you both use? Jasmine stated that she reads her bible and meditate a lot, however Dilan stated that he does neither.

5. Do you see the natural goodness in people, goodness in the natural world, and lives of animals? Both stated that they see good in people, but disagreed about the world and animals

MENTAL STATUS EXAMINAION

Please conduct this on the identified patient (IP) only. Mark each item as either mild, moderate, or severe. These are not questions you ask the IP, but rather can ascertain through the intake process.

Appearance:

Unkempt, disheveled Non-Applicable Mild Moderate Severe

Clothing, dirty, atypical Non-Applicable Mild Moderate Severe

Odd phys. Characteristics Non-Applicable Mild Moderate Severe

Body odor Non-Applicable Mild Moderate Severe

Appears unhealthy Non-Applicable Mild Moderate Severe

Posture:

Slumped Non-Applicable Mild Moderate Severe

Rigid, tense Non-Applicable Mild Moderate Severe

Body Movements:

Accelerated, quick Mild Moderate Severe

Decreased, slowed Mild Moderate Severe

Restlessness, fidgety Mild Moderate Severe

Atypical, unusual Non-Applicable Mild Moderate Severe

Speech:

Rapid Mild Moderate Severe

Slow Mild Moderate Severe

Loud Mild Moderate Severe

Soft Mild Moderate Severe

Mute Non-Applicable Mild Moderate Severe

Atypical (e.g., slurring) Non-Applicable Mild Moderate Severe

Attitude:

Domineering, controlling Mild Moderate Severe

Submissive, dependent Mild Moderate Severe

Hostile, challenging Mild Moderate Severe

Guarded, suspicious Mild Moderate Severe

Uncooperative Mild Moderate Severe

Affect:

Inappropriate or inconsistent with thought Mild Moderate Severe

Increased lability Mild Moderate Severe

Blunted, dull, flat Non-Applicable Mild Moderate Severe

Euphoria, elation Mild Moderate Severe

Anger, hostility Mild Moderate Severe

Depression, sadness Mild Moderate Severe

Anxiety Mild Moderate Severe

Irritability Mild Moderate Severe

Perception:

Illusions Mild Moderate Severe

Auditory hallucinations Non-Applicable Mild Moderate Severe

Visual hallucinations Non-Applicable Mild Moderate Severe

Other hallucinations Non-Applicable Mild Moderate Severe

Cognitive:

Alertness Mild Moderate Severe

Attention span, distractibility Mild Moderate Severe

Short-term memory Mild Moderate Severe

Long-term memory Mild Moderate Severe

Judgment:

Decision making Mild Moderate Severe

Impulsivity Mild Moderate Severe

Thought Content:

Obsessions/compulsions Mild Moderate Severe

Phobic Non-Applicable Mild Moderate Severe

Depersonalization Non-Applicable Mild Moderate Severe

Suicidal ideation Non-Applicable Mild Moderate Severe

Homicidal ideation Non-Applicable Mild Moderate Severe

Delusions Non-Applicable Mild Moderate Severe

Orientation:

Person (x1) Yes No

Place (x2) Yes No

Time (x3) Yes No

Situation (x4) Yes No

Level of Insight:

Complete denial Non-Applicable Mild Moderate Severe

Blames others Mild Moderate Severe

Intellectual insight, but few changes likely Mild Moderate Severe

Emotional insight, understanding, change can occur Mild Moderate Severe

Slight awareness Mild Moderate Severe

Self-Blames Mild Moderate Severe

SYMPTOM CHECKLIST

Please check the symptoms that the family is currently experiencing. Please indicate to which family member you are referring, as well as duration and severity.

There are several ways to assess for suicide risk. Dependent upon the IP, please select one of the following at document the level of risk:

https://www.integration.samhsa.gov/images/res/SAFE_T.pdf

https://www.integration.samhsa.gov/clinical-practice/Columbia_Suicide_Severity_Rating_Scale.pdf

https://teenmentalhealth.org/wp-content/uploads/2014/09/TASR-Am.pdf

IP Jasmine- reports feelings of sadness when it comes to her family and intimate relationship with Dilan. She reports inability to concentrate and obsessive thought patterns. IP also reports that she sometimes has feelings of tension and anxiety when it comes to getting things done such as meeting deadlines. IP reports that she often time feel hostile and has displayed compulsive behaviors such as cleaning her house. IP reports uncontrollable anger outburst. IP reports that she often has strange thoughts like when she is in a crowded room, she is always looking for an exit. She reports that she has a phobia to being in closed areas or feeling smothered due to past abusive relationships. However, IP reports having feelings of suicidal ideations in lifetime, but no attempts. IP agreed to a more in-dept psych-evaluation and has signed consent giving consent to release information to Spindletop MHMR here in Beaumont and Family Services for psychotherapy.

__X___High/Severe

____Moderate

_____ Low

Reference:

COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) (2008). In Health Resources &

Services Administration. Retrieved from https://suicidepreventionlifeline.org/wp-

content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-

2014.pdf

Robinson, ., & Taylor, . (n.d.). Assessment Biopsychosocial. Retrieved from https://learn-us-

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