Intake

 Using the blank to develop a client intake 

Appendix C

© 2016 Cengage Learning

Wildwood Case Management Unit
Intake Assessment Form

Client Name____________________________________ Agency # _________________

D.O.B. ________________________________________ Date of Assessment _________

1. PRESENTING PROBLEM (Functional impairment, symptoms, background)

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

Appendix C

© 2016 Cengage Learning

Education

Occupation

Finances

Psychosocial & environmental problems

4. CURRENT MEDICAL CONDITIONS
Condition Physician Treatment

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

5. PREGNANT YES NO

Receiving prenatal care? YES NO

Prenatal Care from

Due Date

Complications

6. PRIMARY CARE PHYSICIAN

Date of last physical examination

Appendix C

© 2016 Cengage Learning

7. CURRENT MEDICATIONS
Name/Dosage Prescribed by Condition

Side effects

Medication allergies

8. RELATIONSHIP RISK FACTORS;
Is client safe at home? YES NO

Does client feel threatened in any way? 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

Appendix C

© 2016 Cengage Learning

9. 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)
Previous attempts or episodes

Evaluation of suicide risk

( ) none ( ) slight ( ) moderate ( ) significant ( ) extreme ( ) no plan ( ) plan (describe)

Evaluation of violence risk

( ) none ( ) slight ( ) moderate ( ) significant ( ) extreme ( ) no plan ( ) plan (describe)

10. MENTAL STATUS EXAM
Appearance

( ) age appropriate ( ) well groomed ( ) disheveled/ unkempt ( ) bizarre ( ) other

Orientation

( ) person ( ) place ( ) time ( ) situation

Behavior/Eye Contact

( ) good ( ) limited ( ) avoidant ( ) none ( ) relaxed/calm ( ) restless ( ) 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

Appendix C

© 2016 Cengage Learning

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

Judgment

( ) intact ( ) age appropriate ( ) impulsive ( ) immature ( ) impaired ( ) mild

( ) moderate ( ) severe

Insight

( ) intact ( ) limited ( ) very limited ( ) fair ( ) none ( ) aware of current disorder

( ) understands personal role in problems

Appendix C

© 2016 Cengage Learning

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

Interviewer summary of findings (add details where appropriate)

11. SUBSTANCE USE/ABUSE

Type Amount
used

How taken Duration Frequency Date of last
use

Tobacco

Alcohol

Illicit Drugs

Prescription
Drugs

OTC Drugs

Other

Appendix C

© 2016 Cengage Learning

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 hide 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

Appendix C

© 2016 Cengage Learning

12. CLIENT REQUESTS, GOALS, EXPECTATIONS

13. CLINICAL SUMMARY (Using information you have collected summarize—identifying
possible relationships—conditions and causes that may have led to current situation)

14. IMPRESSIONS

15. RECOMMENDATIONS

16. DSM 5 DIAGNOSTIC IMPRESSION

_____________________________________________________
Case Manager Signature Date

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