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INTAKE ASSESSMENT
CLIENT NAME: _____Jane Doe_______________________
DATE OF BIRTH: ____00/00/63___________________________
DATE OF INTAKE: _____12/8/98__________________________
CHIEF COMPLAINT: Client complained of “obsessive-compulsive” behavior. Client
reported frequent handwashing, teethbrushing, and showering (approximately 12
times/day), as well as house cleaning. Client also stated she combs her hair frequently and
washes with clorox and alcohol. Client stated she is “anorexic;” she reported that she
rarely has an appetite and only “can stomach bagels.” She also stated that she “vomits”
frequently, but that this vomiting is involuntary and not due to a fear of gaining weight.
Client reported there has been no medical cause found for her lack of appetite or
vomiting.
CLIENT PROFILE: Client is a 34-year-old Caucasian divorced female. She recently
moved into an apartment in Anytown with her two sons (ages 10 and 11). Client reported
she graduated from high school and received training as a certified nurse’s assistant.
Client stated she is currently unemployed and received disability.
HISTORY OF PRESENTING PROBLEM: Client reported her symptoms began five
years ago when her husband left her for another woman. Client stated she felt “dirty”
because her ex-husband got this woman pregnant. Client reported a history of depressive
symptoms (how long these symptoms have persisted is unclear) and a five-year history of
OCD behavior. Client reported that she has “heard [her] neighbors breathing and
thumping” in her bedroom, so she leaves and “wanders” around her parking lot and
around town. Client stated she hasn’t done this in a while (again, time frame is
uncertain), however. Client stated she was “monitored” for OCD behavior in a hospital
about one year ago. Client also stated she threatened to commit suicide at this time, as
well (see psychiatric history). Client was very vague about the history of OCD behavior,
as well as other symptoms and problems she has had in the past. Client stated that she
always has had problems with her appetite and that, as a child, she was “sickly.” Client
denied any physical damage from her frequent washing.
PAST PSYCHIATRIC HISTORY: Client reported that she had been seen by Generic
Therapy Agency in the past (see client’s chart), as well as the Greenhouse Group and
Catholic Memorial Hospital in Generictown last year. Client reported she was
hospitalized for six days for OCD behavior and suicidal ideation. Client denied any other
prior treatment.
SUBSTANCE ABUSE: Client denied any drug or alcohol use.
SOCIAL HISTORY: Client reported she was born and reared in Anytown, USA. She
stated she has two older brothers and two older sisters. Client stated she doesn’t know
where the oldest brother is and hasn’t seen him in a while. Client stated that her other
siblings live in the Anytown area. Client reported her mother and father are married and
spend winters in Florida and summers in Maine. Client characterized her relationships
with her siblings and parents (other than her oldest brother) as “close,” although she
reported that she doesn’t have much contact with them. Client stated she did “well” in
school but didn’t have any friends. Client reported a short, sporadic work history, which
included jobs in fast food restaurants and dry cleaning. Client stated after her divorce she
lived with a boyfriend, as well as other acquaintances. Mostly, she stated that these
arrangements dissolved because of poor relations. Client stated that she still sees her
boyfriend “occasionally.” Client also reported that she doesn’t have any friends. Client
stated she was married in 1985 and divorced in 1993. Client characterized her marriage
as “good” and “close,” although client reported her husband was having affairs
throughout their marriage. Client made reference to her children being “taken away” by
the state, but she didn’t offer any information as to why (see client’s chart for history).
RELEVANT FAMILY HISTORY: Client reported that her oldest brother has been
diagnosed with “manic depression.” Client’s records indicate that this brother may have
schizophrenia. Client also stated that her brother-in-law committed suicide about seven
years ago. Client denied any other family history.
MEDICAL HISTORY: Client complained of lung and kidney infections, as well as
thyroid disease. Client stated Dr. Feelgood is currently seeing her for these problems.
Client stated her mother has diabetes, and her father has high blood pressure.
MENTAL STATUS:
General: Client appeared fairly well groomed with good hygiene. Client made good eye
contact throughout interview.
Attitude: Client seemed cooperative and help seeking; however, at times, she seemed
eager to have someone guide her and give her advice. Client’s motivation to work on
problems appeared rather limited as evidenced by some passivity and vagueness in
describing problems and symptoms.
Motor Activity: Movements appeared fluid; no involuntary or unusual movements noted.
Speech: Rate, volume, and pressure seemed normal; speech was content-rich
Affect: Affect was somewhat flat with constricted range. At times, content was not
appropriate to context or mood congruent (as evidenced by flat affect or lack of affect
when speaking of painful memories).
Mood: Mood was vague; mood did not vary much and also seemed somewhat devoid of
emotion.
Thought Form: Thought form was logical, focused, and goal directed.
Suicidal/homicidal ideation: Client denied any suicidal or homicidal ideation.
Delusions: None noted or reported.
Hallucinations: None noted. Client denied any recent hallucinations.
Obsessions/compulsions: Frequent grooming and use of clorox and alcohol (see
presenting problem).
Cognition: Client was oriented to person, place, and time. I.Q. is in the normal range; no
learning disabilities noted.
Insight: Questionable. Client appears to have some dependent qualities (she asked me to
call food pantry to see if they would deliver because of her lack of transportation;
however, she called Phone Company to see about service and handled the call well).
Client appears to be concealing information and seems somewhat manipulative. Client
made several trips to the bathroom before the interview, but showed no discomfort or
need to wash during the interview.
DIAGNOSTIC FORMULATION:
AXIS I: 300.3 Obsessive-Compulsive Disorder
R/O 300.4 Dysthymic Disorder
R/O 296.34 Major Depressive Disorder, Severe with Mood Congruent
Psychotic Features
AXIS II: R/O 301.20 Schizoid Personality Disorder with Dependent Features
AXIS III: Lung/kidney infections, thyroid disease, lack of appetite
AXIS IV: Economic problems and access to health care
AXIS V: GAF current: 40
past year: 40
DIAGNOSTIC FORMULATION: As client presents, she meets all criteria for Obsessive
Compulsive Disorder (A: compulsions as defined by repetitive behaviors and behaviors
aimed at reducing stress; B: client realizes behavior is excessive; C: behavior causes
marked distress; D: compulsions are not restricted to another Axis I disorder; E: not due
to physiological effects of substance). Criteria for Dysthymia and Major Depressive
Disorder with psychotic features need to be ruled out. Client complains of some
depressive symptoms and hallucinations, but does not meet the criteria for these disorders
(or schizophrenia) as of yet. For example, she does not report feeling sad or down.
Client does not meet criteria for eating disorders. Client also meets all the criteria for
Schizoid Personality Disorder (A: doesn’t desire close relationships, chooses solitary
activities, has little interest in sex, takes pleasure in few activities, lacks close friends,
shows emotional coldness and affectivity), but Major Depressive Disorder must be ruled
out first before establishing this diagnosis. At the present time, client does not meet
criteria for Dependent Personality Disorder.
INITIAL TREATMENT PLAN: Established appointment for next week. Will discuss an
evaluation with Dr. Wood; client expressed a desire to do so. Will explore treatment
goals with client next week and work on differentiating diagnoses.
_________________________________________
Therapist Signature
__________________
Date
_________________________________________
__________________
M.D. Signature
Date
(clinic: intasses)
Staffing:
Staffing Date: _______________________