Clinical Considerations for a Strength-Based Intake Assessment
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1 Clinical Considerations for a Strength-Based Intake Assessment Initial Comments/ Assessment Summary 1. Client Demographics - Name: Age: Gender: Race: Note: Domain areas assess the identified child only - except Family/Relationships. Relevant information about family members should be included on page Referral Source - Child Welfare: Juvenile Justice: Education: Mental Health: Corrections: 3. Presenting Concerns (that lead to referral) and Strengths- Abuse: Alcohol/Drugs: Attention: Behavior: Danger (self/others): Psychiatric Symptoms (anxiety, depression, etc.): Disabilities/Challenges: Family Relationships: Legal: Peers: School:
2 2 Psycholog ical/emotional 1. Mental Status (see checklist: Supplement I) Appearance: Well-groomed, appropriate, inappropriate, poor hygiene, disheveled, Gang oriented clothing, alcohol-drug-tobacco oriented clothing, other Concentration: Good, limited, poor Orientation: Person self/others, place, purpose Psychomotor: WNL, agitated, hyperactive, slowed, tics, other Mood/Affect: Euthymic, appropriate to content, calm, cooperative, angry, anxious, Defensive, depressed, flat, labile, euphoric, suspicious, tense, Withdrawn, other Thought Content/Process: Logical, sequential, goal directed, blocking, delusions, grandiose, Hallucinations, paranoia, perseveration, rapid, slowed, spontaneous, Tangential, other Memory: Good, fair, poor Remote Recall: Good, fair, poor Estimated IQ: <Average, Average, >Average Impulse Control: Good, fair, poor Level of Consciousness: Alert, lethargic, other Judgment: Good, fair, poor Insight: Good, fair, poor 2. Treatment History Previous (with dates and provider names): Inpatient: Outpatient: Day Treatment: Residential: Group Home: Foster Care:
3 Counseling: 3 Current: Same as previous : 3. Diagnostic Information in support of diagnosis (see checklist: Supplement II)- Examples: ADHD (i.e. fidgets, distracted, difficulty following directions, unable to stay on task, trouble remaining seated, etc.) Major Depression (i.e. irritable mood, sleep/appetite disturbance, suicidal ideation, depressed mood, feelings of worthlessness, fatigue etc.) Bipolar Disorder (i.e. mood disturbance, manic behavior, hypo manic behavior, depressive symptoms, and associated symptoms related to mania and depression per DSM IV). Anxiety/PTSD (i.e. physical/somatic symptoms, worrisome, fearful, obsessive, compulsive, recurrent dreams/flashbacks of traumatic event, etc.) Oppositional Defiant Disorder (i.e. defies adult requests, temper, arguments, resentful, blames others, swearing, etc.) Conduct Disorder (i.e. illegal activity, physically cruel to animals, fire setting, destruction of property, etc.) 4. Global Assessment of Functioning Scale (CGAS for youth under 14) - Current Score: History: Description/Rationale (see scale): 5. Traumatic Events - Abuse: Deaths: Incarcerations: 6. Parental Concerns - Behavior: Emotions: Eating: Sleeping
4 Toileting: 4 Family/Relationships 1. Family Marital Status: Significant others (paramour) Separations Divorces Marriages Widow/Widower Orientation Siblings: Birth Order: Extended Family (biological, non-biological): Adoptions: Out-of-home placements: Other Caregivers: Custody/Guardianship Arrangements: Living Situations: Family Functioning (ability to parent, substance abuse, legal, etc.): Health: 2. Other Significant Relationships (past and present) Friends: Neighborhood: Community: 3. Sexual Activity Current: History: Pregnancy: STD: Treatment: Safety: 4. Traumatic Events: Deaths: Incarcerations: Abuse: Note: All relevant information about family members goes in this section.
5 5 5. Other Family Member Information (summarize life domain areas): Safety/Crisis 1. Risks and Supports What are the Strengths? Suicide: Thoughts Plans Attempts Supports available When and how? Homicide: Thoughts Plans Attempts Supports available When and how? Self-Mutilation: Thoughts Plans Attempts Supports available When and how? Aggressiveness: Verbal Physical Property Fire Cruelty to Animals Supports available When and how? Abuse: Emotional Verbal Physical Sexual Rape Domestic Violence Neglect Supports available When and how? Separation Issues and Neglect: Supports available Runaway: Purpose Destination Duration
6 Dangerousness/Safety How Returned Crisis Involvement (YES) 6 2. Current Crisis Plans and Plans for Safety - What are the Strengths? Family Solutions: System Supports: Leg al 1. Legal Involvement Probation (type): Parole: Incarceration: Runaway: DCS/CPS/CHINS: Illegal activities: Pending Charges: Substance Use 1. Substances Substances (list): Quantity: Frequency: Last Use: Method: Use Behaviors (where, with who, etc.): Triggers: 2. Current/Previous Treatment History - What are the Strengths? Inpatient: IOP:
7 Support groups (12step, AA, NA, etc.): 7 Educational/Vocational 1. Educational Status - School and School District: Special Education (category and type): Other Educational Services: Accommodations/Educational Supports: Current Educational Performance: IQ (if available from Psych/Ed Testing): 2. Vocational Status - Employment (current, history): Vocational Education or Services: Vocational Goals: Vocational Skills: Health/Medical 1. Health Conditions (vision, dental, physical, etc.) - Current: Previous: 2. Medical Events: Accidents: Surgeries: Emergency Procedures: 3. Treatment-
8 Primary Care Physician: Psychiatrist: Dentist: Optometrist: Other Health Professional: Hospitals Used: Medications and Prescriber: Last Appointment: 8 Home/Place to Live 1. Home Environment - Moves: Recent Changes: Placement: Family House/Apartment: Status and Impression: Family Satisfaction: 2. Neighborhood - Location: Family Satisfaction: Daily Living 1. Strengths - Skills (age appropriate): Abilities (age appropriate): Resources (age appropriate): Goals (age appropriate): 2. Needs - Skills (age appropriate): Abilities (age appropriate): Resources (age appropriate): Goals (age appropriate):
9 9 Cultural/Spiritual 1. Culture - Ethnicity: Traditions (holidays, rituals, etc.): 2. Religion - Affiliation: 3. Beliefs - Spiritual: Cultural: Values: 4. Community Involvement - Churches: Groups: Organizations: Financial 1. Medical Insurance - Type: Status: 2. Financial Supports/Income - Employment:
10 Child Support: System Support (AAP, SSI, etc.): 10 Social/Recreational 1. Youth Activities - Fun: Hobbies: 2. Family Activities - Fun: Hobbies: 3. Social Activities Home: Neighborhood: Community:
11 11 Supplement I : Mental Status Checklist Appearance: well groomed appropriate inappropriate poor hygiene disheveled gang oriented clothing alcohol, drug, or tobacco oriented clothing other Concentration: good limited poor Orientation: person place purpose time Psychomotor: WNL agitated hyperactive slowed tics other Mood/Affect: appropriate to content calm cooperative angry anxious suspicious defensive depressed flat labile euphoric suspicious tense withdrawn other Thought Content/Process: logical, sequential, goal directed blocking delusions grandiose hallucinations paranoia perseveration rapid slowed spontaneous tangential other Level of Consciousness: alert lethargic other Short-Term Memory: good fair poor Remote Recall: good fair poor Estimated IQ: below average average above average known IQ Assessor Impulse Control: good fair poor Judgment: good fair poor
12 12 Supplement II : Diagnostic Information Checklist ADHD Often fidgets/restless Difficulty remaining seated Easily distracted Difficulty awaiting turn in games or groups Often blurts out answers to questions Has difficulty following instructions from others Often shifts between incomplete activities Has difficulty playing quietly Often interrupts others Does not seem to listen Loses things Engages in physically dangerous activities Duration = months TRAUMA AND ANXIETY SYMPTOMS Sleep or Appetite disturbance: Worrisome: Fearful: Restless and/or Irritable Physical/somatic complaints (list): Obsessions (list): Compulsive behavior Recurrent recollection or dreams of traumatic event Flashbacks to traumatic event: Difficulty concentrating Intense psych stress at exposure to cues that symbolize traumatic event Duration = months Evidence of traumatic event OPPOSITIONAL DEFIANT DISORDER Often loses temper Argues with adults Defies or refuses adult requests or rules Deliberately does things to annoy people Often blames others for his/her mistakes Touchy or easily annoyed by others Angry or resentful Spiteful/vindictive Swears or uses obscene language Duration = months MAJOR DEPRESSION Depressed mood Irritable mood Lack of interest/pleasure in activities Appetite disturbance Sleep disturbance Psychomotor agitation/retardation Fatigue or loss of energy Feelings of worthlessness Excessive/inappropriate guilt Difficulty concentrating Indecision Recurrent thoughts of death Suicidal ideation Duration = months +CONDUCT DISORDER Aggressive to people/animals Destruction of property Theft or deceitfulness Serious violation of rules probation runaway truancy illegal activities Duration = months MENTAL RETARDATION: Mild: to 70 Moderate: to Severe: to Profound: below Borderline Intellectual Functioning: Suspected/Unknown/Need Testing
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