Intake Assessment Form PDF

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Intake Assessment Form Directions: Complete the Intake Assessment below using Part I of the case study of Allison. Complete the form, some items have already been completed for you. 1. Client Information Client’s Name: Allison Williams Date of Assessment:

08/06/2020

D.O.B.

1/26/1996 Age: 24

Sex: F

Face-to-Face: Yes/No

Time Involved: 2hrs Primary language: English

Method of communication: Verbal 2. Presenting Problem

Description of the client’s perception: The client is in a state of depression and having thoughts of suicide due to past hurts and other abandoning her weather its family, friends, or past relationships. This depression has led the client in a downward spiral seeking alcohol and marijuana to dull the feelings of pain and the emotions of worthlessness. Also, the client has use pain pills such as 250 milligram ibuprofen and marijuana in order for her to sleep at night, she stated “it helps me sleep.” She reports that she has stopped attending classes and her grades are failing. The client was fired from her job as a waitress two months ago, because the client frequently missed work and when the client was there, the client’s boss told her she was just “not friendly to the customers.” The client also reports that she is feeling overwhelmed. Level of distress expressed by client: None mild moderate severe 3. Psychological, behavioral information Description and history of presenting problem: Allison reports her father and mother divorced when she was 17 years old. The client reports that she has had little contact with her father who moved to a different state and started a new family shortly after the divorce and has a half sister and brother that she have never met. Also, she has many pasted fail relationships. Duration of problem and current episode: The client states that she has had a series of relationships over the past four years, but nothing “serious: until this last relationship. The client states, “I thought I would marry him. Everyone always leaves me." Allison reports that she has one older brother (26 years old) and one younger sister (16 years old). Allison reports she has a “distant” relationship with her mother. The client states that they were never close and that her mother has quit contacting her. Allison reports that during the last six months she began missing classes and withdrawing from her friends. She feels as if she has nothing to live for without her boyfriend and that life will not get any better. Over the course of the last month, Allison has been slipping deeper into © 2013. Grand Canyon University. All Rights Reserved.

depression and relying more on alcohol and marijuana to get through each day. The client states I usually just drink beer, but sometimes I drink vodka and orange juice or rum and coke if I can afford it. Allison states that lately she has begun to smoke marijuana because “it helps me sleep.” Allison reports that she takes a few “hits” on her pipe per day.

Previous attempts to resolve, including help sought from other sources: When meeting with her case manager, Allison appeared to be wearing clothes that she slept in and her hair was unwashed, hanging in her face. She had been crying and had bags under her eyes. She sat quietly, staring at the floor, with her arms folded around herself, as if giving herself a hug. At times, it appeared as if she was rocking back and forth. When she arrived, Allison slowly walked back to the case manager’s office, looking at the floor. Allison reports that she is feeling overwhelmed. She states that nothing she does will make it better, and that she will never fall in love again. She states that nothing is enjoyable anymore, and the only way she can dull the feelings of pain and the emotions of worthlessness is to drink but when she is intoxicated, she just feels worse. She knows that driving while drinking or after becoming drunk is not safe and is illegal, but she cannot seem to stop. Allison reports that she is not eating well and does not have enough energy to do anything. She also says she is not sleeping well and needs to drink so that she can fall asleep easier. Potential for injury to self/others: The client is causing potential harm or injury to themselves due to the fact of using different pain meds and street drugs in order to get to sleep and is falling deeper into depression and relying more on alcohol and marijuana to get through each day. Also, her use of alcohol is hurting her mentally, psychologically, and emotionally. Suicidal: Yes/No Explain: The Client told the officer that when she got out of jail, she had some pills in her home that she was planning on taking to “just to sleep.” Therefore, the officers placed Ms. Williams on suicide watch. Self-Mutilating: Yes/No If yes, explain: The client is self-mutilating herself with the use of alcohol therefore the scars may not be external but internal. Violent/Homicidal: Yes/No If yes, explain: Yes, the client has been violent/homicidal. The client has drove driven several times under the influence of alcohol and marijuana, therefore causing potential harm or homicide to others. Describe plan, available means, intent, and urgency: Recommendation for the client is to be placed in a facility or outpatient therapy for mental health and substance abuse treatments, be placed on some type of anti-depressant such as Zoloft, Wellbutrin, Fluoxetine, Citalopram, Escitalopram, Paroxetine, and Fluvoxamin for depression and attend Alcoholics Anonymous meeting twice a week.

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History of suicidality: If yes, describe: No, there is no history of suicidality History of violent/assaultive behavior: If yes, describe: No, there is no history of violent/assaultive behavior

© 2015. Grand Canyon University. All Rights Reserved....