Description
Develop a problem and a complete history of the client. Use the attached assessment form to complete your report.
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Explanation & Answer
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Intake Assessment Form
Client Name Bob Smith______________________________________ D.O.B.
04/22/1947__________________
Unit # __Psych________ Date of
Assessment__9/15/2016________________________________________
1. PRESENTING PROBLEM (Functional impairment, symptoms, background)
__Bob does not seem to know where he is and was wandering around confused in the
street._______________________________________________________________________
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2. CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES
AGENCY/PERSON
PHONE
SERVICE
DATE
n/a Just starting intake
process______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
FAMILY
__Bob has no
family._______________________________________________________________________
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SOCIAL
_Bob has no local friends and seems very antisocial. He just moved here from
California.____________________________________________________________________
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SUPPORT
___Bob seems to have no
support.______________________________________________________________________
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LEGAL
_Bob does not have a prison
record.______________________________________________________________________
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EDUCATION
___Bob says he is a retired
doctor._______________________________________________________________________
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OCCUPATION
___Bob says he is a retired doctor buy I am not sure if he is a doctor of college or a medical
doctor of some
kind.________________________________________________________________________
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____________________________________________________________________________
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_
FINANCES
Seems to have no
resources.____________________________________________________________________
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