Adult Intake Report. Visits held for completion of intake (Indicate dates):

Transcription

1 Dean Hope Center for Educational and Psychological Services Teachers College, Columbia University Box 91, 525 West 120 th. Street, New York, N.Y Tel. (212) Fax. (212) Dinelia Rosa, Ph. D., Director Adult Intake Report Client s name: Age: Date of Birth: Date completed: Student: Visits held for completion of intake (Indicate dates): Client previously seen at CEPS? Yes no If yes, describe when and for what service. Referral source: (Describe who referred the client; if self referred please indicate) Reason for referral: (Describe reason for referral according to the source of referral; briefly describe the kinds of problems experiencing that have led to seek services) Procedures used to obtain intake information: Client interview Self-report measures (describe below) Review of material brought by client Existing material in client s file (Please specify): Attitude toward examiner: Normal Abnormal (explain) BYOPSYCHOSOCIAL ASSESSMENT Gender (please select one): Male Female Transgender Don t know/unsure/prefer Not to Answer 1

2 Client: Student: Race or Ethnicity (mark all that apply): White Black/African-American Hispanic/Latino/Chicano Arab/Middle-Eastern Religious Affiliation (please select one): Christian: Protestant Christian: Catholic Christian: Nondenominational Jewish Muslim None Sexual Orientation (please select one): Straight/Heterosexual Gay/Lesbian/Homosexual Bisexual Asian Native American/American Indian/Alaska Native Native Hawaiian/Pacific Islander Don t Know/Unsure/Prefer Not to Answer Hindu Buddhist Spiritual/Personal Beliefs Atheist Agnostic Don t Know/Unsure/Prefer Not to Answer Asexual Questioning Don t Know/Unsure/Prefer Not to Answer Current living situation: Apartment Owned co-op Homeowner Alone With family with roommates DESCRIPTION OF CLIENT Appearance: Appears stated age Average weight unusually tall for age Younger than stated age obese unusually short for age Older than stated age Thin other (please specify): Dressing: Season setting age Inappropriate for time Season setting Business Sport Other (please specify): 2

3 Client: Student: Grooming Clean Well-groomed tidy Unkempt Dirty Unusual odor (Perspiration, alcohol, etc.) Wearing bright colors wearing dull colors Posture & Gait: Normal Stiffness Prefers to lie on one side Mechanic Movements Abnormal (explain) Facial expression: Appears sad perplexed worried blank Fearful excited elated interested Preoccupied bored suspicious dazed Smiling responsive animated tense Eye-contact: Appropriate poor indirect inconsistent Fleeting glaring darting no contact CHIEF COMPLAINT Using the client s own words in quotes, wherever possible briefly state why the client is seeking help now. Do these problems make it hard to manage daily responsibilities? This would include things like keeping bathed and groomed, cooking for yourself, getting to places you need to go, managing money, keeping your living space organized, etc. If so, please describe. 3

4 Client: Student: Other sources of stress: Health Work Education Interpersonal History of presenting problem: Describe onset, previous struggles with the problem, attempts to cope with previous situations; Describe if, when and where prior professional help was sought, and outcomes. Past psychiatric history: Chronologically detail significant past psychiatric symptoms and treatments, including hospitalizations (with dates) and prior psychotropic medications along with responses and any adverse effects. Records must be requested; please place copy of request in chart. Describe any history of suicidality, assaultiveness, and or homicidality. ALCOHOL AND SUBSTANCE ABUSE In the table below, indicate how much the client is using currently in about the past month or so. In the right column, indicate how much the client used during a period of time when he/she were using the most. Past History Per Day Per Week Per Month Alcohol Reg. Cigarettes Other Tobacco/ Nicotine Marijuana Substance Name Name Other 4

5 Client: Student: Current Per Day Per Week Per Month Alcohol Reg. Cigarettes Other Tabacco/ Nicotine Marijuana Substance Name Name Other Have you experienced problems in any of these areas due to alcohol or drug use (mark all that apply)? DEVELOPMENTAL, SOCIAL AND MEDICAL HISTORY a) Gestation, infancy, childhood, adolescence, and adulthood Significant event in gestation infancy childhood childhood adulthood Describe below: b) Psychosexual history Uneventful Sexual Molestation (describe below) Sexual abuse (describe below) History of incest (describe below) Sexual Violence (describe below) Describe any significant history around sexual orientation development. c) Educational/Vocational history Describe education history including coping skills used to address academic challenges. Describe the client s career course, and specialized job training. Work history including most recent job; military service; selfassessment of successes and failures, etc. What is the client s current source of income? Is there any history of public assistance or disability (with dates and rationale)? 5

6 Client: Student: d) Social history Describe the nature of client s social growing up, and now. Is the client currently involved in social activities? What is his or her current social network? What is the client s perception of his or her current social life? What is the client s history of significant love relationships? e) Criminal/Legal history None Yes (describe below) On probation Past Present On parole Past Present Probation - Occurs prior to and often instead of jail or prison time Parole - An early release from prison. If on parole, provide name and telephone number of parole officer. Psychiatric treatment required by court Yes No History of carrying a weapon No Yes If yes, at present? Yes No Family history: a) Family of origin composition and significant history: Single In common-law relationship Married Separated Divorced Blended family Described the indicated above: b) Current family composition and significant history: Single In common-law relationship Married Separated Divorced Blended family Describe the indicated above; also significant indicators of SES; client s earliest memory of family; quality of relationships, frequency of contacts: significant family events, moves, discipline style and attitude of caregivers; nature of current relationships to parents, and other family members; family crises or significant death and how client coped with it. b) Family psychiatric and medical history Medical Uneventful Significant (Describe whom and condition (s) below) Following treatment? Yes (describe below) No (Why, describe below) N/A Psychiatric Uneventful Significant (Describe whom and condition (s) below) Following treatment? Yes (describe below) No (Why, describe below) N/A Describe psychiatric condition (s), psychotic disorders, affective disorders, anxiety disorders, OCD, dementia, etc.) 6

7 Client: Student: Medical history: Uneventful Significant (Describe condition (s) below) Surgery (describe below) Following treatment? Yes (describe below) No (Why, describe below) N/A Describe psychiatric condition (s), psychotic disorders, affective disorders, anxiety disorders, OCD, dementia, etc.) Most recent medical examination: Name current prescribed medications: Name any current non-prescribed medications: MULTICULTURAL EVALUATION a) Language Primary language: Upbringing language: If bilingual: Preference to speak to family: N/A Preference to speak to friends: N/A Preference to watch T.V. N/A Participating in therapy N/A If English is not the client s primary language, describe client s expressive English language skills: Fluent Intermediate Basic Beginner b) Migration history, if applicable: Place of birth: If born outside the U.S., age when enter U.S. In country of origin, grew up in: Rural area nearby city city Reason for migration: Economic Political both Describe any significant history related to migration, was the client separated from significant others; how did he react and cope with separation; do they keep in touch; what significant others does client has in the U.S.; if client visits native country, indicate reason and frequency. What is the attitude of native country toward mental illness/treatment? If client moved from another region of United States, describe any related migrating issues. If migrations or separations affected family structure, describe the role of extended family in client s life. Note any other family structure issues. c) Acculturation issues How long living in the U.S? How many generations living in the U.S? Any difficulty in adaptation to U.S. culture? Describe 7

8 Client: Student: d) Cultural and racial identity What is the client s self-perceived cultural identity? Does client identify self as belonging to a distinctive cultural or ethnic group? Specify. Does client identify with a distinctive racial group? Explain. e) Spiritual/Religious history Upbringing - Describe spiritual beliefs and religious practices, current religion, religion of upbringing; how often practices religious services and activities; do religious practices or spiritual beliefs have an impact on treatment; how; any significant religious/spiritual beliefs or explanations to presenting problem; have client consulted religious leader/healer regarding his, or her presenting problem please explain. Indicate any recommendations given and their impact. Additional religious factors: (e.g., change of religions, religious beliefs affecting treatment, etc.) Mental Status Examination Appearance Unkempt, disheveled Clothing, dirty, atypical Odd physical characteristics Body odor Appears unhealthy Posture Slumped Rigid, tense Body Movements Accelerated, quick Decreased, slow Restlessness, fidgety Mechanic movements Stiff Atypical, unusual Orientation Time Person Place Speech Rapid Slow Loud N/A or WNL Slightly Impaired Moderately Impaired Severe Impaired 8

9 Soft Pressure Mute Atypical (e.g., slurring) Attitude Eye contact Domineering, controlling Submissive, dependent Hostile, challenging Guarded, suspicious Uncooperative Mood Depressed Anxious Angry Affect Inappropriate to mood Increased lability Blunted, dull, flat Elated & euphoric Hostile Sadness Irritability Perception Illusions Auditory Visual Tactile Olfactory Other Hallucinations Auditory Visual Tactile Olfactory Other Thought Process Goal Oriented Blocking Incoherent Irrelevant Circumstantial Tangential Perseveration Flight of Ideas Intellectualization Thought Content 9

10 Delusions Persecutory Grandiose Somatic Referential Influential Nihilistic Self-accusatory Other Suicidal Ideations Homicidal Ideations Obsessions Phobic Depersonalization Cognitive Attention Concentration Alertness Blunting of Attention Preoccupation Distractibility Short-term memory Long-term memory Level of Intelligence Vegetative Signs Eating Pattern Sleeping Pattern Judgment Decision making Impulsivity Insight To current state Life in general Denial Blames others Awareness Blames self Summary Impressions: a) Cultural formulation (Please refer to the DSM-5, Other Conditions that may be a Focus of Clinical Attention, p. 715) Describe the cultural identity of client. Is client providing a cultural explanation for the presenting problem? What are the predominant idioms of distress through which symptoms, or the need for social support is communicated, the meaning and perceived severity of the symptoms in relation to norms of the cultural reference group? Are there cultural factors related to the psychosocial environment that is affecting the level of functioning? What are the cultural elements of the relationship between the client and the clinician? Indicate multicultural differences. Does client s presentation fall in any of the Culture-Bound Syndromes described in the DSM-IV- TR? What is the overall cultural assessment for diagnosis and care? How cultural considerations 10

11 Client: Student: specifically influence a comprehensive diagnosis and care. Summarize the impact of cultural components in client s presenting problem. b) Clinical formulation Describe clinical impressions. Summarize your understanding of the nature, causes and psychodynamics of the client s problem; state your assessment of the client s motivation and expectations for treatment; describe the client s strengths and weaknesses; integrate your own insights and relevant data from the preceding sections in this section. Include all major diagnostic and treatment considerations. What are the client s adaptive capacities and positive attributes? Include coping style and coping mechanisms. Provide supportive reasoning behind the diagnosis. Describe the client s subjective psychic world, and varied experiences of individual attachment relationships. What is the client capacity to relate to others? What is the client s worldview of the outside world and others? What is the client s self-representation in relation to others? Describe client s cognitive development. Diagnosis: DSM-5 Indicate Rule Out Deferred or None when necessary. Diagnosis 1:. Diagnosis 2:. Diagnosis 3:. Prognosis Excellent Good Moderate Guarded Marginal Poor Qualifiers for Prognosis Med. compliance Tx. compliance Home environment Activity changes Behavioral changes Attitudinal changes Educational/training Other: Treatment Considerations: Is the client appropriate for treatment? Yes No If no, explain and indicate referral made: Treatment modality recommended: Individual Dynamic CBT IPT ERT Family/Couple DBT Group Poor Other Services Needed: Physical Exam School Records Lab Tests Medical Records Psychological eval. Neuropsych. eval. Other 11

12 Client: Student: If you are not planning to continue with the client, give pertinent details about the disposition being considered. Final disposition decisions are made by the CEPS director; but you should state here what you propose. Whether continuing with client or not, this section is also the place to spell out any ancillary activities that should be part of the service plan such as conjoint referral to psychological testing, request hospital records, or request school reports. Case Disposition: (Please indicate as many as needed) Current trainee will provide service Refer to another trainee in DHC Refer out for services Describe: Trainee s name: Trainee s signature: Date: Supervisor s name: Supervisor s signature: Date: 12