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
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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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