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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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