ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT. Name: Date: Referred by:
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1 ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT Name: Date: Referred by: Date of Birth: SSN: Identifying Information (age, marital status, ethnicity, and sex) 1. Reason for Referral: (Why are you here? Describe problems, i.e., behavioral and/or situational changes, losses, major symptoms, recent conflict with family members/ others) 2. Background Information: Place of Birth: Parent s age and occupation: (If deceased, please include age, year, and cause of death) Siblings: (Give names and ages of brothers and sisters) Birth Order: (Which child were you; 1st, 2nd, etc.?) Current Marital/Relationship Status: Length of Marriage/Cohabitation: Sexual Orientation Number of Marriages/Significant relationships(explain): Spouse/ Significant other employment status: Children s names and ages: (Include step-children) 1
2 Current Living Arrangement/ With whom do you live and where? 3. Family Psychiatric History: (History of ADHD, bipolar, depression, anxiety, schizophrenia, learning disorders, mental retardation, drug/alcohol abuse, attempted suicide, completed suicide, incarceration). Your brothers or sisters, or your children: Father and/or relatives: Mother and/or relatives: 4. Educational History: Elementary school: Middle School: High School: Year Graduated: College: GPA Year Graduated: Degree: Extracurricular Activities: (Clubs, sorority/fraternity, band) Describe Relationships with peers: (teased, bullied, well-liked, respected, etc.) Special Education Classes: Y N If yes, what type of class? Repeat a grade: Y N If yes, what grade? Suspended: Y N Explain: Expelled: Y N Explain: If you did not complete high school, explain: Any problems before the age of 18 for the following: Fight with Teachers Use a Weapon Skip School Cruel to other children Stealing Member of a gang If checked, explain: 2
3 5. Employment History: Military History: (Give Rank/Discharge/Duties/Years Discharged) Current Employment: Position: Length and duties: Co-worker relations: List previous employment, length, reason for change (termination), and co-worker relations: Have you ever received any of the following: Social Security Benefits: Y N Explain: Workers Compensation: Y N Explain: Personal Injury Benefits: Y N Explain: Financial Problems (Any history of bankruptcy, foreclosure, etc.) 6. Legal History: Any contact as a child or adolescent with: Youth Court Y N Training School Y N DHS Y N If yes to above,explain: As an adult: Current Charges Y N Past Charges Y N DUI Y N If yes to above, give dates and charges: 7. Developmental/Medical History: During your mother s pregnancy, labor, or delivery, were there problems? Y N If yes, explain: History of physical/sexual/emotional abuse and/or neglect? (Include perpetrator, length of abuse, age of occurrence, and type) Did you have developmental delays? Any delays walking, talking, toileting? Y N If yes, explain: Any major childhood illness, injuries, or surgeries? 3
4 Any history of the following illnesses: Diabetes Heart Disease Seizure Arthritis Ulcers Glaucoma Tuberculosis Thyroid Hypertension IUV Hepatitis Seizures STD s Head Injuries Car Accidents Explain: Significant Surgery & Date(s): Date of Last Physical Primary Care Physician: Any current medical/physical problems: Name of Medication Dosage (amt. and frequency) Purpose Medication compliance Y N If no, explain 8. Nutritional Screening: (Consult Registered Dietician if 3 or more Y responses) Special Diet Y N Overweight Y N Underweight Y N N Poor Appetite Y N Unintentional Weight Loss/ Gain Y N Binge/Purge Y N 9. Psychiatric History: Outpatient treatment/name of Therapist: Dates: Psychiatrist (for medication): Dates: What medications have you taken in the past? Have you ever been hospitalized for emotional or behavioral reasons? Y N If yes,, give the name of the hospital and the dates of treatment: Have you ever received psychological testing? If so, give the name of the psychologist and the reason and date of testing. 4
5 10. Drug and Alcohol History: Age of first tobacco use: History of tobacco use: (frequency, duration(s), period(s) of abstinence) How many packs a day do you smoke? Age of first alcohol use: History of alcohol use: (frequency, duration(s), period(s) of abstinence) How many alcoholic drinks do you have in a day? Age of first illegal/prescription drug use/abuse: History of illegal drug use: (frequency, duration(s), period(s) of abstinence) Have you ever had any drug/alcohol treatment? If so, state where and when, and state if you completed treatment: 11. Current Information and Daily Activities: Any problems with hygiene and grooming: Y N If yes, explain Describe a typical day for you, from the time you get up in the morning until you go to bed at night. Describe your support system: Describe your relationships with friends, family, and peers (school, home and/or church): Are you involved in any group or community activities: (i.e., church, civic clubs, etc.) If so, where and how often? What do you enjoy doing with your leisure time? (hobbies, sports, and interests) Additional Information: Is there anything that we did not ask that you need to tell us? 5 **STOP HERE**
6 Mental Status Hygiene/grooming/posture: Behavior: Calm Restless Fidgety Tremulous Motor Agitation Motor Retardation Hyperactivity Uncooperative Tics Poor Eye Contact Friendly/Cooperative Speech: Tone: Loud Normal Soft Slurred Rate of Speech Rapid Normal Pressured Mumbled Articulation deficits Slow Expressive or receptive deficits Thought Processes: Coherent Incoherent Flight of Idea Thought Blocking Paucity of Ideas Overproductive Goal Directed Tangential Relevant Circumstantial Evasive Loosening of Associations Oriented X Affect: Normal Restricted Flat Blunted Irritable Suspicious Grandiose Sad Elevated Labile Angry Other Mood: Depression Elation Euphoria Anxiety Fearfulness Withdrawal Isolation Angry Belligerence Incongruent Inappropriate Euthymic 6
7 Cycles of Mood Instability: History of manic behavior: Panic symptoms: Somatic: Pain Sleeping Eating Weight Change N/A Suicidal History: Current Suicidal Ideation: Thought Content: Delusions Obsessions Phobias Suspicion N/A Ideas of Reference: Religious Persecutory Grandiose Hallucinations: Visual Auditory Tactile Olfactory N/A Give onset, frequency, and content Intellectual Level: Above Average Average Below Average 7
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