Download Intake Interview

Intake Interview
Name:
Center Location:
Time In:
DOB (Age):
Marital Status:
Education:
Time Out:
Race:
Number of Children:
Employer:
Date:
Sex:
Referral Source:
Self-referred
Court-mandated (Single point of entry: Civil commitment: 7 or 45 days)
Family (i.e., spouse, parents)
Psychiatrist or physician
School referred (FINN petition)
Reason for Referral:
“To assess personality characteristics.”
“To assess present intellectual functioning.”
“To clarify X’s current diagnoses of X and rule out diagnoses of X.”
“Due to X’s presenting problems consisting of depression, schizophrenia, or anxiety.”
“To assess X poses a clear and present danger or self or other.”
“To assess X can be awarded the custody of the minor child.”
Presenting Problems:
“Presenting problems upon the intake interview include depressive symptoms, anxious symptoms, or
schizophrenic symptoms.”
(*Make sure to specify problems in terms of intensity, frequency, duration, and precipitating situations).
History of Presenting Problems:
“X’s symptoms reportedly began in 2002, and were exacerbated when X happened.”
Client’s Expectation for Therapy:
“To overcome depression.”
(*Make sure to assess whether or not one’s expectations are realistic, specific, and appropriate).
Social History:
Family-of-Origin History and Relationships:
Family members (parents, siblings), their ages/jobs, places living, description of them, etc.
Early Childhood Development:
“No clinically significant problems/complications at birth/pregnancy or in early development were
noted. X achieved all developmental milestones on time”
Any developmental issues? Delays? Sexual or physical abuse? Accidents or trauma?
Education/Vocational History:
Need to include “Degree, strength/weakness, grade, which school X attended or which program (i.e.,
special ED or resource classes) was placed in, and etc.”
X works where and how long?
Marital and Interpersonal History:
Spouse, divorce, relationships, or friends.
Hobbies, interpersonal/social activities.
Chemical Use History:
“Denies any significant history of substance abuse and alcohol.”
“X reportedly began smoking X at the age of X, and would smoke an ounce per week.”
“X drank heavily until X became at age 16.”
Legal Involvement:
“X reports no present legal difficulties. Nevertheless, X has been charged with X in 2002 and had to pay
$ fine for doing that.”
Arrest, charges, or convictions?
Cultural, Ethnic, and Spiritual Factors:
“X goes to X Baptist church in X.”
Medical History/Health Status:
List medical problems, onset, frequency, medications, hospitalizations, and etc.
Mental Health History:
“X apparently has an extensive psychiatric history dating back to approximately X when X was
hospitalized at X for a month due to X.”
“X has taken X medication since 2002. X has been responsive to the medication.”
Mental Status Examination:
-Appearance:
“X was appropriately groomed and dressed. “
“Appears to be at X’s stated age of X.”
“Personal hygiene was fair.”
-Attitude:
Cooperative, rebellious, negative, guarded, defensive, etc.
-Affect: (somewhat transient, fluctuating changes in emotional “weather” compared to mood)
Flat (absence of any sign of affective expression)
Blunted (significant reduction in the intensity of emotional expression)
Restricted or constricted (mild reduction in the range or intensity of emotional expression)
Labile (abrupt, rapid, or repeated shifts in affective expression)
Inappropriate or incongruent (discordance between affective expression and the content of speech and
ideation).
-Mood (more pervasive and sustained emotional “climate” compared to affect):
Dysphoric (an unpleasant mood such as sadness, anxiety, irritability)
Euthymic (mood in the normal range without depression or elation)
Elevated (an exaggerated feeling of well-being such as euphoria or elation)
Irritable (easily annoyed or provoked to anger)
Expansive (lack of restraint in expressing one’s feelings such as grandiosity)
-Insight:
“X understands the consequence of X’s behavior.”
“X lacks insight into X’s problems.”
-Speech:
“Speech rate and volume were of normal range or within the normal limits.”
Alogia (lack of speech or content)
Flight of ideas (a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that
are usually understandable. Pressured speech).
Incoherent (incomprehensible speech or thoughts due to a meaningless or illogical connection between
words or phrases within a clause).
Derailment or loosening of associations (a pattern of speech in which a person’s ideas slip off one track
onto another that is unrelated. Between clauses).
Dysarthria (imperfect articulation of speech due to disturbances of muscular control).
Echolalia (parrotlike speech such as repeating a word or phrase just spoken by another person).
-Motor Activity:
Ataxia (complete or partial loss of coordination of voluntary movement)
Cataplexy (i.e., sudden bilateral loss of muscle tone resulting in collapsing being often associated with
laughter, anger, fear, or surprise).
Dyskinesia (i.e., distortion of voluntary movements with involuntary muscular activity: side effects).
-Behavior:
Catatonic behavior
-Echolalia (parrot-like speech such as repeating a word or phrase just spoken by another person).
-Echopraxia (repetition by imitation of movements of another)
-Excessive activity such as apparently purposeless agitation not influenced by external stimuli
-Extreme negativism such as motiveless resistance to instructions or attempts to be moved.
-Motoric Immobility such as
Catalepsy (i.e., waxy flexibility such as rigid maintenance of a body position for a long time)
Stupor (i.e., unresponsiveness with immobility)
-Mutism
Stereotyped behavior (repetitive, nonfunctioning behaviors such as hand shaking or waving, body rocking,
head banging, mouthing of objects, picking at skin, or hitting one’s own body).
Stereotyped behavior (repetitive and nonfunctional behaviors such as hand shaking or waving, body
rocking, head banging, mouthing of objects, self-biting, picking skins, hitting one’s own body).
“X behaved in a passive-aggressive manner during the interview.”
“No signs of catatonic behaviors or stereotyped behaviors were noted.”
-Memory:
“Short and long term memories were intact.”
(*What is my name? Name three states.”)
-Judgment:
Intact? Understand the consequences of behavior. Impulsive or hyperactive?
-Intelligence:
“Appears to be above (or below) average, although no formal testing for current intellectual functioning
was conducted.”
-Appetite/Sleep Disturbance:
“Initial, middle, terminal insomnia.” Nightmare. Weight loss or gain.
-Perceptual Experiences:
Illusion (misperception of a real external stimulus)
Hallucination (perception of things without a real external stimulus: Visual, auditory, tactile, gustatory,
somatic)
-Orientation:
“X was oriented to time, place, and people.”
-Thought Content:
Invariant thoughts (i.e., I always have been and always will be a coward)
Irreversibility (i.e., I am sick, there is nothing I can do”)
Non-dimensional and global (I am fearful and that’s it)
“Must, Should” rather than “Will, Want, Can.”
Negative views of self, other, and world (i.e., I am bad).
Delusional? (A false belief based on incorrect inferences such as bizarre, grandiose, erotomanic,
persecutory, of being controlled, somatic, thought broadcasting, thought insertion).
Entitled.
Unfairly treated
Overvalued ideas
-Thought Processes:
Absolutistic, dichotomous thinking (i.e., placing all experiences in one of two opposite categories)
Arbitrary inference (i.e., drawing a specific conclusion in the absence of evidence to support the conclusion
or when the evidence is contrary to the conclusion)
Catastrophic (i.e., always think of the worst)
Circumstantial.
Ideas of reference (i.e., a belief that casual incidents or external events have a particular meaning and
unusual meaning that is specific to the person. If there is a delusional conviction, then a delusion of
reference).
Magnification and minimization (faulty information processing in evaluating the significance of an event)
Magical thinking (a belief that one’s thoughts, actions, or words will cause or prevent a specific
outcome in a way that contradicts laws of cause and effect).
Overgeneralization (response) (i.e., Drawing a general rule or conclusion based on one or few isolated
incidents)
Selective abstraction (stimuli) (focusing on a detail taken out of context ignoring other more salient features
of the situation)
Personalization (i.e., tendency to relate external events to oneself when there is no basis for making such a
connection).
Perfectionistic
-Attention and Concentration:
Distractibility, hyper-vigilant, or focused?
-Level of Consciousness:
Alert
-Risk Factor:
Suicidal or homicidal, drug, driving, gang members, sexual or physical abuse?
Diagnostic Impression:
Axis I Depression, Anxiety, Schizophrenia, Substance Abuse, etc
Axis II Personality Disorders, Mental Retardation
Axis III Medical Conditions (i.e., migraine, cancer ulcer, etc)
Axis IV Psychosocial and Environmental Problems
With primary support group (i.e., death or health problems in family, divorce)
With Social environment (i.e., difficulty with acculturation, living alone)
Educational problems
Occupational problems
Housing (i.e., homeless)
Economic problems
Problems with health care services (i.e., no health insurance)
Problems with legal system (i.e., arrested?)
Other (i.e., exposed to disaster?)
Axis V: GAF = (current or at discharge?)
(On a scale of 0 to 100)
Integrated, Interpretive Summary:
“X is a X-year-old, race, married/divorced, widowed, male/female, who grew up or live in X with X.”
Referred by whom?
Presenting problems upon the intake interview include Xs.
Case conceptualization: “X appears to show these symptoms due to Xs (i.e., stressors, divorce, economic
hardship, discord with spouse, medical conditions, substance abuse, etc).”
“X appears to meet the diagnostic criteria for X. May need to rule out a DX.”
Therapeutic barriers include Xs (i.e., noncompliance with medication, defensive, guarded, not motivated
for therapy, no transportation, etc.)
Positive factors affecting treatment include Xs (i.e., intelligent, cooperative, motivated, insightful, etc.)
Treatment goals include Xs (i.e., reduce depressive symptoms, reduce disruptive behaviors, increase social
skills, expand interpersonal relationships, increase pro-social behaviors, etc.)
The recommended treatment modalities include Individual therapy, group therapy, family therapy,
medication adjustment, and case management.
X will benefit from interventions such as Xs (i.e., parenting training, communication skills training,
behavior modification intervention, support therapy, systematic desensitization technique, cognitive
restructuring, reality testing, social skill training, etc.)
Treatment is appropriate and should involve psychiatric medication management as needed and weekly
individual therapy. The anticipated length of care is approximately X months. There are no patient
discharge needs anticipated at this time. X will be referred to a psychiatrist for an evaluation and
assessment for medication needs.
Interviewer: