Clinical Intake Assessment


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Clinical Intake Assessment

Hickory Grove Counseling Center 7200 E WT Harris Blvd. Charlotte, NC 28215 Phone: 704-531-4034 Fax: 704-531-4069

Name: _____________________________________________________________DOB: _____________________________ Reported by: _________________________________________________________________________________________ Interview Dates: _____________________________________________________________________________________ Identifying Information: Age: _______ School/Workplace: _____________________________________________________________________ Grade/Position: ______________________________________________________________________________________ Phone Number: ______________________________________________________________________________________ Address: ______________________________________________________________________________________________ _________________________________________________________________________________________________________ Marital/Relationship Status: _______________________________________________________________________ Psychosocial: Race/Ethnicity, Culture, Social, Factors: ________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Living Arrangement (including names and ages of people living in household): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Sexual Experience History: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Childhood History: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Diagnosis Information: Admitting Diagnosis, DSM IVTR (if available): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Most recent evaluations and assessments completed (please provide copies of psychiatric assessments, if applicable): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Current Diagnosis: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Presenting Problem: First noticed: _________________________________________________________________________________________ Problem Description: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Steps tried to resolve problem: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Has anything worked/What has worked (to some extent): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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Mental Health Information: Family History of Mental Illness or Substance Abuse: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Client History of Mental Illness or Substance Abuse: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Client History of Mental Health Treatment: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Client History of Previous Psychiatric Hospitalization: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ History of Medications (Approximant date taken and name of medication): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Current Medications: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Family and Social History, including current circumstances and special needs that may impact therapy: Previous living situations (Include previous moves, reasons why moved): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Biological Parent’s involvement: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Step Parent’s involvement (if applicable): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Family Composition (including custodial and non-custodial parent): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Parent’s Marriage status (including dates of separation and divorce if applicable): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Reason for separation/divorce (if applicable): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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Mental Status: Mood/Affect (Check all that apply and explain): o Euphoria/elated _____________________________________________________________________________ o Irritable ______________________________________________________________________________________ o Pleasant ______________________________________________________________________________________ o Angry _________________________________________________________________________________________ o Hostile ________________________________________________________________________________________ o Anxious _______________________________________________________________________________________ o Depressed ____________________________________________________________________________________ o Sad ____________________________________________________________________________________________ o Blunted _______________________________________________________________________________________ o Other _________________________________________________________________________________________ Daily Patterns (Check all that apply and explain): o Increased Appetite __________________________________________________________________________ o Decreased Appetite __________________________________________________________________________ o Binging _______________________________________________________________________________________ o Purging _______________________________________________________________________________________ o Increased sleep need ________________________________________________________________________ o Decreased sleep need _______________________________________________________________________ o Poor quality sleep ___________________________________________________________________________ o Fatigue _______________________________________________________________________________________ o Nightmares __________________________________________________________________________________ o Social withdrawal ___________________________________________________________________________ o Other _________________________________________________________________________________________ Thought/Perceptual Content (Check all that apply and explain): o No Items reported ___________________________________________________________________________ o Hallucinations Check Type: ___Auditory ___Visual ___Olfactory ___Tactile o Delusions Check Type: ___Paranoid ___Grandiose ___Bizarre ___Homicidal ___Suicidal ___Self Harm o Ideas of reference Check Type: ___Ideation ___Urges ___Plans (last 48 hours) o Comments: ________________________________________________________________________________ ________________________________________________________________________________ History of Client’s Harmful Behavior (Check all that apply and explain): o Suicide ________________________________________________________________________________________ o Violence ______________________________________________________________________________________ o Self Harm _____________________________________________________________________________________ o Risky Sexual Behavior ______________________________________________________________________ o Other _________________________________________________________________________________________

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History of Harmful Behaviors in Client’s Support Network (Witnessed, experienced in home, behaviors directed toward client, etc.): o Suicide ________________________________________________________________________________________ o Violence ______________________________________________________________________________________ o Homicide _____________________________________________________________________________________ o Self Harm _____________________________________________________________________________________ o Substance Abuse _____________________________________________________________________________ o Other _________________________________________________________________________________________ o Neglect _______________________________________________________________________________________ o Verbal Abuse _________________________________________________________________________________ o Physical Abuse _______________________________________________________________________________ o Sexual Abuse _________________________________________________________________________________ History Of Grief and Loss: Explain any loss experienced by the client or family that may affect the client (IE. Death, miscarriage, etc.…): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Explain how client and/or family dealt with the loss: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Describe current daily activities of client: o Sunday ________________________________________________________________________________________ o Monday _______________________________________________________________________________________ o Tuesday ______________________________________________________________________________________ o Wednesday ___________________________________________________________________________________ o Thursday _____________________________________________________________________________________ o Friday _________________________________________________________________________________________ o Saturday ______________________________________________________________________________________ Describe prior and/or current drug/alcohol use/abuse (if applicable): Date(s) started: ______________________________________________________________________________________ Substance used: ______________________________________________________________________________________ Date(s) quit use: _____________________________________________________________________________________ Treatment Received: ________________________________________________________________________________ Other comments: ____________________________________________________________________________________

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Children/Adolescents/Adult Past: Academic Difficulty (Include grades, issues in certain subjects, etc.…): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Behavior Problems at School (With authority figures such as teachers, principles, etc.…): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Developmental Difficulty (Past and present issues with meeting developmental markers): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Peer Relationship Problems: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Behavior Issues at Home: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Discipline Techniques used by Parent(s)/Guardian(s): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Sexually Active? ______________________ Age of 1st sexual experience: _______________________ Parents’ thoughts on the subject of sex: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Legal: (Please provide most recent custody or court summary to therapist) o Custody Agreement (IE, Joint, Primary, etc.): _____________________________________________ o Custody is with: ______________________________________________________________________________ o Resident is with: _____________________________________________________________________________ o Visitation schedule: _________________________________________________________________________ _________________________________________________________________________________________________ o Who has medical making ability: ___________________________________________________________ o Is DSS Involved? (If so, why?): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ o Court Involvement (If so, why?): _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ o Court hearings pending: ____________________________________________________________________

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Medical: Any Past or Current Medical Issues: _______________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Hospitalizations: _____________________________________________________________________________________ Date of last Physical Exam: __________________ Doctor’s Name: _____________________________________ Any issues found at appointment: __________________________________________________________________ _________________________________________________________________________________________________________ Females: o Age of first menstrual cycle: ________________________________________________________________ o Issues associated with menstrual cycle: ___________________________________________________ _________________________________________________________________________________________________ o Birth Control? _________ What Kind? __________________________________________________ Age client started taking birth control: ____________________________________________________ o Is client pregnant? ________________________ Due date: _____________________________________ Nutrition/Physical Activity: Eating Schedule: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Vitamins (if so, what kind): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Adequate Fluid Intake (what does client drink, any dehydration issues): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Is client following a special diet? (If so, give the purpose and a description of the diet): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any weight change? (If so, explain why so): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Exercise Schedule (Include activity, how many times per week, and duration): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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Religion/Spiritual Orientation: Client’s Spirituality/Religion: _______________________________________________________________________ Brief Spiritual/religious history (if applicable): __________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Importance in client’s life: __________________________________________________________________________ How does it currently affect client’s life? __________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Church, Synagogue, Mosque, Temple, or any other place you attend for religious/spiritual purposes: _____________________________________________________________________________________________ _________________________________________________________________________________________________________ How often/How involved? ________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Do you want this to be a part of counseling? ______________________________________________________ If so, How? ____________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Why did you choose a counselor at Hickory Grove? ______________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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Goals of Therapy (What you want to get out of therapy): 1. _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ _________________________________________________________________________________________________ Therapist Conclusions (To be completed by the therapist after assessment): _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Client Signature: _____________________________________________________________________________________ Guardian Signature: _________________________________________________________________________________ Therapist Signature: ________________________________________________________________________________ Date completed: _____________________________________________________________________________________



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