MY B.R.O.T.H.E.R.S. HOUSE, INC.
Richard L. Taylor, III, Executive Director
4822 Albemarle Road, Suite 105
Charlotte, North Carolina 28205
Office Phone (704) 532-4770
Fax Phone (704)532-4774
Intake Assessment
Client Name:______ID#: ______
Date of Referral: ______Date of Intake: ______Location: ______
Parent(s)/Guardian Name(s): ______
1. Presenting Issue(s)/Reason for Referral (Chief complaint. Indicate duration, frequency and severity of behavioral symptoms)
______
Check all that can be identified as current family or client issues:
Family Client
_ Physical abuse _Substance/Alcohol use/abuse _Sexual abuse (including suspected) _School truancy, behavior problems _Emotional abuse _Academic Performance
_Domestic violence _ Runaway
_Parenting _Anger / Aggression
_Custody issues _Depression
_Substance/alcohol use/abuse _Oppositional / Defiant
______
______
2. Mental Health History / Agency Involvement: (Indicate agencies at which services received, dates and hospitalizations).
3. Medical Profile: (Significant medical problems, illness, injuries, known allergies, current physical complaints or medications). ___None Reported
4. Educational / Vocational Status: (School, grade, special ed/IEP status, behaviors, suspensions, expulsions, any changes in academic functioning related to stressors, peer relations).
5. Current Living Situation and Supports: (Daily routines, relationships and interactions affecting client and family’s functioning).
6. Legal Profile: (Indicate client’s criminal just status). Please circle for each.
Y N Pending charges (see comments)
Y N Currently on probation
Y N Court hearing date ______
Y N Past convictions (see comments)
Y N Past incarceration (see comments)
Comment:
7. Drug and Alcohol Profile: (Substance use / abuse of client / family members).
___None Noted
(Person) (Type of Substance) (Frequency/ Duration)
______
______
______
______
8. Resources and Strengths: (Include strengths and supports of client and family).
9. Diagnosis:
Axis I:
______
______
Axis II:
______
______
Axis III: ______
______
Axis IV: ______
Axis V:
*Note Primary diagnosis cannot be adjustment disorders, substance abuse or V- codes) CAFAS Score (if applicable)
10. Assessment Summary / Recommendations: (Document the current need for services).
11. Recommended Discharge Goals:
______
Signature/Title of Person Completing Assessment Date
______
Signature/Consumer Date
______
Signature/Legal Guardian or Responsible Party Date
______
Signature Date