Intake Assessment

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Humanities

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Refer to the example presented in the content section of the course to conduct an intake assessment on a friend or classmate. Develop a problem and a complete history of the client. Use the attached assessment form to complete your report.

Intake Assessment Form is attached

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Diagnostic Assessment CONFIDENTIAL Client Name: John Smith DOB (Age): 6/10/2000 (7) School: ABC Elementary Grade: 2nd Examiner: Jane Doe Date(s) of Evaluation: 11-9-07, 11-10-07 Identifying Information John is a 7-year-old Hispanic male who was self referred to the XYZ clinic. Reportedly, the mother picked up a clinic brochure in the waiting room of their pediatrician’s office. John’s mother, Julie Smith, reports that since pre-K-4 John has been acting out at school, especially during after care. Additionally, Mrs. Smith mentioned that John has significant difficulty completing homework at home and easily becomes angry, calls other people names, and at times expressing his anger physically by throwing a tantrum or kicking in response to not getting his way. Mrs. Smith is interested in receiving services from the XYZ clinic to help them manage John’s behavior at home and at school. Presenting Problem Mrs. Smith reported that John’s behavioral problems first became noticeable during preK-4. According to Mrs. Smith, John is the class clown at school. He will use “potty” language such as saying “poopy butt” or “peepee head” and sits on his head on his chair to make other children laugh. Mrs. Smith also reports that John does not get along well other children in his class. Reportedly he annoys the other children, and in response they verbally pick on him. They will call him names and will come up to her after class to tell her what he said to them. At home, Mrs. Smith mentioned, that on a daily basis she can expect a problem while completing homework after arriving home from after care. Mrs. Smith mentioned that at times he may complete the one assignment without difficulty, but after seeing how much he still has to complete he will begin to avoid homework, while other days it is a struggle to even start one assignment. According to Mrs. Smith, when John becomes upset with homework, he will throw his papers around and say things like “this is stupid” or “I hate school!” Mrs. Smith reported that John gets along well with his sister Lindsey. Although at times John will reportedly break things of his sister’s, and will get into verbal fights with her. History of Presenting Problem Reportedly, John attended QRS preschool and had no considerable problems; however upon switching schools to a public school for kindergarten, John’s behavioral problems presented, resulting in John being suspended from school for repeatedly acting out in class. In response to his behavioral problems Mrs. Smith enrolled John in a private school that had a better teacher-student ratio. Mrs. Smith mentioned that John’s behavior problems at home have become worse over time. Reportedly, he has stopped performing some of the behaviors he did when he was younger, however his anger has become much more severe. He will now punch the couch, walls, or doors, or will throw toys across the room or break them. Mrs. Smith stated that his anger will come out when he gets in trouble during aftercare, or when he is redirected during aftercare or at home. John will scream and yell for 5-10 minutes before he will begin to calm down. While he is screaming, he will reportedly try to talk his way out of the punishment followed by attempting to avoid being punished. When he is finally put into timeout on the playground at aftercare or at home, he will say, “I hate you” Mrs. Smith reported that John also has significant difficulty completing homework during after care and at home. She mentioned that he will initially run off and hide when it is time to start homework. When he is found the other after care supervisors will say “you are going to do your homework” and reportedly, John will begin to work. At home however, Mrs. Smith mentioned that John will complete one subject, typically the easiest, and when he realizes he still has more to complete he will whine about not wanting to finish the rest of his work, which often times turns into a crying episode which can last for 5-10 minutes. Other Relevant History Developmental/Medical History Mrs. Smith reported that during her pregnancy with John she was very anxious but the pregnancy was normal and without any complications. Reportedly, John began to walk when he was approximately 1-year-old. He was toilet trained around 3 years of age, and reportedly he began talking when he was approximately 2-years-old. John's last physical examination was in August of 2007 for a routine checkup. Mrs. Smith mentioned that John has some difficulty falling sleeping and will crawl into bed with her and her husband about 1-2 times per month. Family History John currently lives with his mother, age 32, and step-father, age 35, as well as his younger sister, age three years old. Mrs. Smith, who was born and raised in Florida, obtained her GED and currently works as a teacher’s assistant at QRS School. Mr. Smith earned a high school degree and currently works as a car salesman. Mrs. Smith mentioned that John’s biological father, Bob, left her when John was 2 years old. Reportedly, he has had no contact with John since he was 3-years-old. Mrs. Smith stated that Bob came from an abusive home with an alcoholic father. According to Reportedly, Mr. Smith spends money frivolously, buying “junk” quite often as well as going to gamble and spend substantial amounts of money. Mrs. Smith reported that when she and her husband are together, he is the primary disciplinarian. She also mentioned that she is with John much more often, so she is the primary disciplinarian. Mrs. Smith stated that she has attempted to manage John’s behavior through the use of time out, which is served in his room. In addition to time out, Mrs. Smith reported that she will take away things or privileges such as no television. Educational/Social History John is currently enrolled in the second grade at QRS School in LMN City, Florida. During kindergarten, John attended a local public school during which time he began to demonstrate some behavioral problems which resulted in a suspension from school and Mrs. Smith enrolled John in QRS School. Reportedly, Mrs. Smith will receive reports from the teacher almost everyday, explaining John’s misbehavior. Mrs. Smith mentioned that he is a smart child and believes that John could do very well in school if he would pay attention and put effort into his work. She also mentioned that John does not do what he is told to do by the teachers but not in a defiant fashion and that he does not interact well with his peers. She stated that most other children do not get along with him or like him. Mrs. Smith reported that John annoys the other children and as a result they call him names and pick on him. Mental Status Exam John presented as a typical 7-year-old boy. He is of average height and slightly over weight for his age. He was accompanied by his mother. They arrived on time for the appointment; John was dressed in a school uniform. John was very cooperative to questions asked throughout the interview. He was not able to play by himself while the interviewer spoke with his mother. John’s rate of speech was normal and his volume was appropriate. No hallucinations were reported and no delusions were elicited throughout the interview. John denied suicidal/homicidal ideations, but did mention that he wanted his mom to run over a bully’s bike. No history of abuse or neglect was reported. John showed some signs of concentration problems as evidenced by poor performance in repeating number’s forward and backwards. Special Considerations Academic Needs John learns best through hands on means, and Mrs. Smith stated John gets “bored” by lectures. Mrs. Smith stated that English is primary language spoken in the home. Spiritual Cultural Concerns John is of the Catholic faith. There does not appear to be any spiritual or cultural concerns that would interfere with treatment. Pain Assessment No concerns were reported. Clinical Findings The following problems were identified based on the results of the parent and child interviews: 1. Since kindergarten, John has been demonstrating problem behaviors at home as well as at school. Namely, John has temper tantrums when he is disciplined, is redirected, or is required to complete homework. During these tantrums he will scream and yell, and on occasion punch objects around him, including the sofa, wall, or doors. He will also throw toys and fight with his sisters. Based on his history and current difficulties, a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), Predominately Inattentive type should be considered. Mrs. Smith indicated that six of the nine diagnostic symptoms of inattentiveness are currently present. Symptoms endorsed by the Mrs. Smith include: “Avoids, expresses reluctance about, or has difficulties engaging in tasks that require sustained mental effort,” “Does not seem to listen when spoken to directly,” “Does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace,” “Has difficulty organizing tasks and activities,” “Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities,” “and “Loses things necessary for tasks or activities.” Tentative Treatment Recommendations John is appropriate for outpatient therapy at the Center. The following recommendations are offered to address observed behavioral and social difficulties: 1. Mr. and Mrs. Smith would benefit from parent training in which they would learn appropriate skills for managing John’s behavior. These techniques could include reinforcement procedures, punishment, time-out, and active ignoring, which would help alleviate John’s problems associated with homework completion and impulsivity. 2. Social Skills training would be beneficial for John. Skills that he does not possess such as dealing with teasing and compromising, can be taught and practiced within a clinic setting. These skills can later be generalized to actual situations with his peers. In addition, Good Friends are Hard to Find and Children’s Friendship Training by Fred Frankel Ph.D. would be beneficial for John and his family to read together. These books provide helpful advice for parents and children to assist in developing and keeping relationships with peers. 3. Psychoeducation about Attention Deficit Hyperactivity Disorder and what can be done to help John would be beneficial for the Smith family. Jane Doe, MHP. 03/15/15 Clinical Supervisor: 03/15/15 Intake Assessment Form Client Name _______________________________________ D.O.B. __________________ Unit # __________ 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 ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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 ( ) Magical thinking ( ) Delusional guilt ( ) Nihilistic delusions ( ) Hallucinations ( ) Ideas of inference ( ) Depersonalization ( ) Moderate ( ) Thought withdrawal ( ) 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________________________________________________________________________________________________ _________________________________________________________________________________________________________ ILLICIT DRUGS _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 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 ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ DESCRIBE CIRCUMSTANCES THAT USUALLY LEAD TO RELAPSE ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ IS CLIENT INVOLVED IN AA/NA? ( ) YES ( ) NO _____________________________________________________________________________________________ 11. CLIENT REQUESTS, GOALS, EXPECTATIONS ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 12. CLINICAL SUMMARY (PULL TOGETHER INFORMATION YOU HAVE COLLECTED AND SUMMARIZE, IDENTIFYING POSSIBLE RELATIONSHIPS, CONDITIONS AND CAUSES THAT MAY HAVE LED TO CURRENT SITUATION) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 13. IMPRESSIONS ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 14. RECOMMENDATIONS ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
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