Expert answer:Intake Assessment
Expert answer:Refer to the example presented in the content section of the course to conduct an intake assessment on a friend or classmate. Develop a problem and a complete history of the client. Use the attached assessment form to complete your report. Intake Assessment Form is attached
diagnostic_assessment_example.docx
wk5_sp_writtinass_caseexampleintake.docx
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Diagnostic Assessment
CONFIDENTIAL
Client Name: John Smith DOB (Age): 6/10/2000 (7)
School: ABC Elementary Grade: 2nd
Examiner: Jane Doe
Date(s) of Evaluation: 11-9-07, 11-10-07
Identifying Information
John is a 7-year-old Hispanic male who was self referred to the XYZ clinic. Reportedly, the
mother picked up a clinic brochure in the waiting room of their pediatrician’s office. John’s
mother, Julie Smith, reports that since pre-K-4 John has been acting out at school, especially
during after care. Additionally, Mrs. Smith mentioned that John has significant difficulty
completing homework at home and easily becomes angry, calls other people names, and at times
expressing his anger physically by throwing a tantrum or kicking in response to not getting his
way. Mrs. Smith is interested in receiving services from the XYZ clinic to help them manage
John’s behavior at home and at school.
Presenting Problem
Mrs. Smith reported that John’s behavioral problems first became noticeable during preK-4. According to Mrs. Smith, John is the class clown at school. He will use “potty” language
such as saying “poopy butt” or “peepee head” and sits on his head on his chair to make other
children laugh. Mrs. Smith also reports that John does not get along well other children in his
class. Reportedly he annoys the other children, and in response they verbally pick on him. They
will call him names and will come up to her after class to tell her what he said to them.
At home, Mrs. Smith mentioned, that on a daily basis she can expect a problem while
completing homework after arriving home from after care. Mrs. Smith mentioned that at times
he may complete the one assignment without difficulty, but after seeing how much he still has to
complete he will begin to avoid homework, while other days it is a struggle to even start one
assignment. According to Mrs. Smith, when John becomes upset with homework, he will throw
his papers around and say things like “this is stupid” or “I hate school!”
Mrs. Smith reported that John gets along well with his sister Lindsey. Although at times
John will reportedly break things of his sister’s, and will get into verbal fights with her.
History of Presenting Problem
Reportedly, John attended QRS preschool and had no considerable problems; however
upon switching schools to a public school for kindergarten, John’s behavioral problems
presented, resulting in John being suspended from school for repeatedly acting out in class. In
response to his behavioral problems Mrs. Smith enrolled John in a private school that had a
better teacher-student ratio. Mrs. Smith mentioned that John’s behavior problems at home have
become worse over time. Reportedly, he has stopped performing some of the behaviors he did
when he was younger, however his anger has become much more severe. He will now punch the
couch, walls, or doors, or will throw toys across the room or break them. Mrs. Smith stated that
his anger will come out when he gets in trouble during aftercare, or when he is redirected during
aftercare or at home. John will scream and yell for 5-10 minutes before he will begin to calm
down. While he is screaming, he will reportedly try to talk his way out of the punishment
followed by attempting to avoid being punished. When he is finally put into timeout on the
playground at aftercare or at home, he will say, “I hate you”
Mrs. Smith reported that John also has significant difficulty completing homework during
after care and at home. She mentioned that he will initially run off and hide when it is time to
start homework. When he is found the other after care supervisors will say “you are going to do
your homework” and reportedly, John will begin to work. At home however, Mrs. Smith
mentioned that John will complete one subject, typically the easiest, and when he realizes he still
has more to complete he will whine about not wanting to finish the rest of his work, which often
times turns into a crying episode which can last for 5-10 minutes.
Other Relevant History
Developmental/Medical History
Mrs. Smith reported that during her pregnancy with John she was very anxious but the
pregnancy was normal and without any complications. Reportedly, John began to walk when he
was approximately 1-year-old. He was toilet trained around 3 years of age, and reportedly he
began talking when he was approximately 2-years-old. John’s last physical examination was in
August of 2007 for a routine checkup. Mrs. Smith mentioned that John has some difficulty
falling sleeping and will crawl into bed with her and her husband about 1-2 times per month.
Family History
John currently lives with his mother, age 32, and step-father, age 35, as well as his
younger sister, age three years old. Mrs. Smith, who was born and raised in Florida, obtained her
GED and currently works as a teacher’s assistant at QRS School. Mr. Smith earned a high
school degree and currently works as a car salesman.
Mrs. Smith mentioned that John’s biological father, Bob, left her when John was 2 years
old. Reportedly, he has had no contact with John since he was 3-years-old. Mrs. Smith stated
that Bob came from an abusive home with an alcoholic father. According to Reportedly, Mr.
Smith spends money frivolously, buying “junk” quite often as well as going to gamble and spend
substantial amounts of money.
Mrs. Smith reported that when she and her husband are together, he is the primary
disciplinarian. She also mentioned that she is with John much more often, so she is the primary
disciplinarian. Mrs. Smith stated that she has attempted to manage John’s behavior through the
use of time out, which is served in his room. In addition to time out, Mrs. Smith reported that
she will take away things or privileges such as no television.
Educational/Social History
John is currently enrolled in the second grade at QRS School in LMN City, Florida.
During kindergarten, John attended a local public school during which time he began to
demonstrate some behavioral problems which resulted in a suspension from school and Mrs.
Smith enrolled John in QRS School. Reportedly, Mrs. Smith will receive reports from the
teacher almost everyday, explaining John’s misbehavior. Mrs. Smith mentioned that he is a
smart child and believes that John could do very well in school if he would pay attention and put
effort into his work. She also mentioned that John does not do what he is told to do by the
teachers but not in a defiant fashion and that he does not interact well with his peers. She stated
that most other children do not get along with him or like him. Mrs. Smith reported that John
annoys the other children and as a result they call him names and pick on him.
Mental Status Exam
John presented as a typical 7-year-old boy. He is of average height and slightly over
weight for his age. He was accompanied by his mother. They arrived on time for the
appointment; John was dressed in a school uniform. John was very cooperative to questions
asked throughout the interview. He was not able to play by himself while the interviewer spoke
with his mother. John’s rate of speech was normal and his volume was appropriate. No
hallucinations were reported and no delusions were elicited throughout the interview. John
denied suicidal/homicidal ideations, but did mention that he wanted his mom to run over a
bully’s bike. No history of abuse or neglect was reported. John showed some signs of
concentration problems as evidenced by poor performance in repeating number’s forward and
backwards.
Special Considerations
Academic Needs
John learns best through hands on means, and Mrs. Smith stated John gets “bored” by
lectures. Mrs. Smith stated that English is primary language spoken in the home.
Spiritual Cultural Concerns
John is of the Catholic faith. There does not appear to be any spiritual or cultural
concerns that would interfere with treatment.
Pain Assessment
No concerns were reported.
Clinical Findings
The following problems were identified based on the results of the parent and child
interviews:
1. Since kindergarten, John has been demonstrating problem behaviors at home as well as at
school. Namely, John has temper tantrums when he is disciplined, is redirected, or is
required to complete homework. During these tantrums he will scream and yell, and on
occasion punch objects around him, including the sofa, wall, or doors. He will also throw
toys and fight with his sisters. Based on his history and current difficulties, a diagnosis of
Attention Deficit Hyperactivity Disorder (ADHD), Predominately Inattentive type should
be considered. Mrs. Smith indicated that six of the nine diagnostic symptoms of
inattentiveness are currently present. Symptoms endorsed by the Mrs. Smith include:
“Avoids, expresses reluctance about, or has difficulties engaging in tasks that require
sustained mental effort,” “Does not seem to listen when spoken to directly,” “Does not
follow through on instructions and fails to finish schoolwork, chores or duties in the
workplace,” “Has difficulty organizing tasks and activities,” “Fails to give close attention
to details or makes careless mistakes in schoolwork, work, or other activities,” “and
“Loses things necessary for tasks or activities.”
Tentative Treatment Recommendations
John is appropriate for outpatient therapy at the Center. The following recommendations
are offered to address observed behavioral and social difficulties:
1. Mr. and Mrs. Smith would benefit from parent training in which they would learn
appropriate skills for managing John’s behavior. These techniques could include
reinforcement procedures, punishment, time-out, and active ignoring, which would help
alleviate John’s problems associated with homework completion and impulsivity.
2. Social Skills training would be beneficial for John. Skills that he does not possess such
as dealing with teasing and compromising, can be taught and practiced within a clinic
setting. These skills can later be generalized to actual situations with his peers. In
addition, Good Friends are Hard to Find and Children’s Friendship Training by Fred
Frankel Ph.D. would be beneficial for John and his family to read together. These books
provide helpful advice for parents and children to assist in developing and keeping
relationships with peers.
3. Psychoeducation about Attention Deficit Hyperactivity Disorder and what can be done to
help John would be beneficial for the Smith family.
Jane Doe, MHP. 03/15/15
Clinical Supervisor: 03/15/15
Intake Assessment Form
Client Name _______________________________________ D.O.B. __________________
Unit # __________ 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
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
EDUCATION
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
OCCUPATION
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
FINANCES
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
PSYCHOSOCIAL & ENVIRONMENTAL PROBLEMS
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. CURRENT MEDICAL CONDITIONS
CONDITION
PHYSICIAN
TREATMENT
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. PREGNANT
(
) YES
(
RECEIVING PRENATAL CARE? (
) NO
) YES
(
) NO
6. PRIMARY CARE PHYSICIAN
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
7. CURRENT MEDICATIONS
NAME /DOSAGE
PRESCRIBED BY
CONDITION
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SIDE EFFECTS
____________________________________________________________________________________
MEDICATION ALLERGIES
____________________________________________________________________________________
7. RELATIONSHIP RISK FACTORS;
IS CLIENT SAFE AT HOME? (
) YES
(
) NO
DOES CLIENT FEEL THREATENED IN ANYWAY? (
) 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? (
NEEDS SHELTER (
) YES
(
) YES
(
) NO
) NO NEEDS PROTECTION FROM ABUSE ORDER (
) YES
(
) NO
8. 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)
9. MENTAL STATUS EXAM
_________________________________________________________________________________________________________
________
APPEARANCE
( ) Age appropriate ( ) Well groomed
( ) disheveled/unkempt
( ) bizarre (
) other
ORIENTATION
( ) Person
( ) Place
BEHAVIOR/ EYE
( ) Good
( ) Limited
( ) Rigid
( ) Agitated
( ) Time
( ) Situation
( ) Avoidant
( ) None
( ) Relaxed/calm
( )
Restless
CONTACT
( ) slumped posture
( ) Tense
( ) Tics
( )
Tremors
MOTOR ACTIVITY
( ) Mannerisms
( ) Motor retardation
MANNER
( ) Appropriate
( ) Trusting
Withdrawn
( ) Catatonic behavior
( ) Cooperative
( ) Inappropriate
( )
(
) Seductive
( ) Playful
( ) Evasive
( ) Defensive
( ) Hostile
( ) Manic
( ) Guarded
( ) Sullen
( )
Passive
( ) Demanding
( ) Inappropriate
boundaries
SPEECH
( ) Normal
( ) Incoherent
( ) Pressured
( ) Too detailed
( ) Slurred
( )
slowed
( ) Impoverished
( ) Halting
( ) Neologisms
( ) Depressed
( ) Irritable
( ) Neurological language
disturbances
MOOD
( ) Appropriate
( ) Anxious
( ) Euphoric
( )
Fatigued
AFFECT
( ) Angry
( ) Expansive
( ) Broad
( ) Tearful
( ) Blunted
( ) Constricted
( ) Flat
( ) Labile
(
) Excited
( )
SLEEP
Anhedonic
( ) Good
( ) Fair
( ) Poor
( ) Increased
( ) Decreased
( ) Initial
( ) Decreased
( ) Weight gain
insomnia
APPETITE
( ) Middle insomnia
( ) Terminal Insomnia
( ) Good
( ) Poor
( ) Fair
( ) Increased
( ) Weight loss
THOUGHT PROCESS
( ) Logical and well organized
( ) Illogical
( ) Flight of ideas
( )
Circumstantial
( ) Loose Associations
( ) Rambling
( ) Obsessive
( ) Blocking
( )
Tangential
( ) Spontaneous
THOUGHT CONTENT
( ) Delusions
( ) Persevera …
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