Expert answer:Case Example Intake Assessment, psychology homewor

Answer & Explanation:Develop a problem and a complete history of the client. Use the attached assessment form to complete your report.
intake_assessment_form.docx

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Intake Assessment Form
Client Name _______________________________________ D.O.B. __________________
Unit # __________ Date of Assessment__________________________________________
1. PRESENTING PROBLEM (Functional impairment, symptoms, background)
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2. CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES
AGENCY/PERSON
PHONE
SERVICE
DATE
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
FAMILY
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SOCIAL
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SUPPORT
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
LEGAL
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
EDUCATION
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
OCCUPATION
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
FINANCES
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
PSYCHOSOCIAL & ENVIRONMENTAL PROBLEMS
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. CURRENT MEDICAL CONDITIONS
CONDITION
PHYSICIAN
TREATMENT
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. PREGNANT
(
) YES
(
RECEIVING PRENATAL CARE? (
) NO
) YES
(
) NO
6. PRIMARY CARE PHYSICIAN
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
7. 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? (
NEEDS SHELTER (
) YES
(
) YES
(
) NO
) 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
_________________________________________________________________________________________________________
________
APPEARANCE
( ) Age appropriate ( ) Well groomed
( ) disheveled/unkempt
( ) bizarre (
) other
ORIENTATION
( ) Person
( ) Place
BEHAVIOR/ EYE
( ) Good
( ) Limited
( ) Rigid
( ) Agitated
( ) Time
( ) Situation
( ) Avoidant
( ) None
( ) Relaxed/calm
( )
Restless
CONTACT
( ) slumped posture
( ) Tense
( ) Tics
( )
Tremors
MOTOR ACTIVITY
( ) Mannerisms
( ) Motor retardation
MANNER
( ) Appropriate
( ) Trusting
Withdrawn
( ) Catatonic behavior
( ) Cooperative
( ) Inappropriate
( )
(
) Seductive
( ) Playful
( ) Evasive
( ) Defensive
( ) Hostile
( ) Manic
( ) Guarded
( ) Sullen
( )
Passive
( ) Demanding
( ) Inappropriate
boundaries
SPEECH
( ) Normal
( ) Incoherent
( ) Pressured
( ) Too detailed
( ) Slurred
( )
slowed
( ) Impoverished
( ) Halting
( ) Neologisms
( ) Depressed
( ) Irritable
( ) Neurological language
disturbances
MOOD
( ) Appropriate
( ) Anxious
( ) Euphoric
( )
Fatigued
AFFECT
( ) Angry
( ) Expansive
( ) Broad
( ) Tearful
( ) Blunted
( ) Constricted
( ) Flat
( ) Labile
(
) Excited
( )
SLEEP
Anhedonic
( ) Good
( ) Fair
( ) Poor
( ) Increased
( ) Decreased
( ) Initial
( ) Decreased
( ) Weight gain
insomnia
APPETITE
( ) Middle insomnia
( ) Terminal Insomnia
( ) Good
( ) Poor
( ) Fair
( ) Increased
( ) Weight loss
THOUGHT PROCESS
( ) Logical and well organized
( ) Illogical
( ) Flight of ideas
( )
Circumstantial
( ) Loose Associations
( ) Rambling
( ) Obsessive
( ) Blocking
( )
Tangential
( ) Spontaneous
THOUGHT CONTENT
( ) Delusions
( ) Perseverative
( ) Distractible
( ) Paranoid delusions
( ) Distortions
( ) Thought insertion
( ) Thought broadcast
( ) Somatic delusions
( ) Ideas of reference
( ) Grandiose delusions
PERCEPTION/HALLUCINATIONS
( ) Illusions
SUICIDE RISK
( ) None
( ) Slight
( ) No Plan
( ) Delusional guilt
( ) Nihilistic delusions
( ) Hallucinations
( ) Ideas of inference
( ) Depersonalization
( ) Moderate
( ) Thought withdrawal
( ) Magical thinking
( ) Significant
( ) Derealization
( ) Extreme
( ) Plan (describe
_________________________________________________________________________________________________________
________________________________________________________________________________
VIOLENCE RISK
( ) None
( ) Slight
( ) No Plan
( ) Moderate
( ) Significant
( ) Extreme
( ) Plan (describe
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
9. MENTAL STATUS EXAM cont.
____________________________________________________________________________
JUDGEMENT
( ) Intact
( ) Age appropriate
( ) Impaired
INSIGHT
( ) Intact
( ) Mile
( ) Limited
( ) Impulsive
( ) Moderate
( ) Immature
( )
( ) Severe
( ) very limited
( ) Fair
( ) None
( ) Aware if current disorder ( ) Understands personal role in problems
SENSORIUM
MEMORY
( ) Alert
( ) Intact
( ) Drowsy ( ) Stupor
( ) Impaired
( ) Obtundation
( ) Immediate recall
( ) Remote
( ) Coma
( ) Amnesia
Type of amnesia
_________________________________________________________________________________________________________
INTELLIGENCE
( ) Average
( ) Above average
( ) Below average
( ) Unable to establish
_——————————————————————————————————————————————————————————
INTERVIEWER SUMMARY OF FINDINGS ( add details where appropriate
10. SUBSTANCE USE/ABUSE
TYPE
OF LAST
AMOUNT
HOW TAKEN
DURATION
FREQUENCY
DATE
USED
USE
_____________________________________________________________________________________________
TOBACCO
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ALCOHOL________________________________________________________________________________________________
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ILLICIT DRUGS
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PRESCRIPTION DRUGS
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
OTC DRUGS
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
OTHER
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
EXPERIENCING:
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
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DESCRIBE CIRCUMSTANCES THAT USUALLY LEAD TO RELAPSE
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IS CLIENT INVOLVED IN AA/NA? (
) YES
(
) NO
_____________________________________________________________________________________________
11. CLIENT REQUESTS, GOALS, EXPECTATIONS
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12. CLINICAL SUMMARY (PULL TOGETHER INFORMATION YOU HAVE COLLECTED AND
SUMMARIZE, IDENTIFYING POSSIBLE RELATIONSHIPS, CONDITIONS AND CAUSES THAT MAY
HAVE LED TO CURRENT SITUATION)
____________________________________________________________________________
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13. IMPRESSIONS
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14. RECOMMENDATIONS
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__________________________________________________________________ …
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