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Assessment and Intake

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Name:  Date: 

SSN:  DCN: ">

Address: 

Telephone Number:  Date of Birth: 



Purpose:  >New client evaluation >Readmission >Consultation



Why is Assessment being requested (Goals and treatment expectations of the individual requesting services):

Behavior that led to Assessment:


Areas of Functioning:

School/Work:


Personal Relationships (Intimate): 

Family Relationships:    > Father involved/present/absent (Describe relationship)

> Mother involved/present/absent (Describe relationship)


Number of children: ">
Names, ages, quality of relationship(s):


Other family relationships:


Social Relationships (Peers/Friends):


Psychological/Personal Functioning (Current symptons):


Personal resources and strengths (including the availability & use of family and peers):


Spiritual: ">  Legal: ">

Prior Mental Health History/Treatment:


Number of admissions: ">  Types of admissions: ">

Alcohol and substance use for the past 30 days:


Substance abuse history (Include duration, patterns, and consequences of use):


Diagnoses

Axis I:


Axis II:


Axis III:


Allergies/Adverse reactions to medications: ">

Axis IV Psychosocial and environmental problems in the last year:
> Problems with primary support group > Problems related to the social environment
> Educational problems > Occupational problems > Housing problems > Economic problems
> Problems with access to health care services > Problems related to interaction with the legal system/crime
> Other (specify):


Axis V Global Assessment of Functioning (GAF) Scale (100 down to 0):
Currently"> Past Year">

Assessment of Currently Known Risk Factors:

Suicide:
> Not Assessed Behaviors:  > Not Known > Ideation only > Plan
> Intent without means > Intent with means

Homocide:
> Not Assessed Behaviors: > Not Known > Ideation only > Plan
> Intent without means > Intent with means

Compliance with treatment:
> Not Assessed > Full compliance > Minimal compliance > Moderate compliance
> Variable > Little or no compliance

Substance Abuse:
> Not Assessed > None/normal use:

> Overuse > Dependence > Unstable remission of abuse > Abuse

Current physical or sexual abuse:
> Not Assessed > Yes > No
Legally reportable? > Yes > No If yes, client is  > victum  > perpetrator
> Both  > neither, but abuse exists in family 

Current child/elder abuse:
> Not Assessed > Yes > No
Legally reportable? > Yes > No If yes, client is  > victum  > perpetrator
> Both  > neither, but abuse exists in family 

If risk exists: client >can  > cannot  meaningfully agree to a contract not to harm
> self > others > both

Risk to community (criminal):

Assessment Recommendations:

Outpatient Psychotherapy: > Individual > Family > Marital/relational > Other

Date report sent to referral source: "> Parent/Guardian: ">
Level of supervision needed:

Type of program:

Residential or long-term placement recommended:
Support services needed:

> Parenting skills/child management > Communication skills > Stress management
> Assertiveness > Other


Legal Services: > Offender program > Sex Offender Groups > Substance abuse
> Victum empathy group > Referral to advocate ">
> Other:
Other:


Referrals for Continuing Services

Psychiatric Evaluation Psychotropic Medications:


Medical Care:


Educational/vocational services:


Other:


Current use of resources/services from other community agencies:


Documents to be obtainded (Release of Information Required):


Other needed resources and services:



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