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INTAKE EVALUATION

This form may be completed and placed in the case file or used as an outline for narrative dictation

I. Identifying Information:
Name:
DOB: / Date of Interview:

II. Presenting Complaint:

III. History of Current Problem:

IV. Past Treatment History:

V. Family and Social History: (Include absence or history of abuse)

VI. Work and Academic History:

VII. Medical History: (Include any known food or drug allergies)

VIII. Mental Status Examination:
A. Appearance
Normal Disheveled Poor Eye Contact Immature Bizarre
Other
B. Motor Status
1. Gait
Normal Slow/Retarded Exaggerated Accelerated
Other
2. Eye Contact
Maintains Avoids Stares
3. Activity Level
Unremarkable Uncoordinated Lethargic Hyperactive
Agitated/Restless / Other
4. Mannerisms Exhibited
None Gestures Twitches/Tics Tremors Grimaces
Other
C. Affect
Appropriate Blunted Labile Inappropriate Tearful
Flat Dramatic
D. Mood
Unremarkable Anxious Depressed Irritable Euphoric
E. What level of distress does the client present?
None Mild Moderate Acute
F. Sensorium
Intact Impaired
If impaired: / was the client oriented to person? / Yes No
was the client oriented to time? / Yes No
was the client oriented to place? / Yes No
G. Memory
Intact Impaired: Intermediate/Short-Term Impaired: Intermediate/Long-Term
H. Thought Content/Process
1. Unremarkable Linear Non-Linear Flight of Ideas
Loose Associations Hallucinations: Auditory/Visual/Tactile/Olfactory
Blocking Paranoia Narcissism Grandiosity Obsessive
Compulsion Circumstantial Tangential Echolalia
Somatic Preoccupations Word Salad Delusions
2. What was the rate of the client’s thoughts?
Normal Accelerated Retarded
3. Were the client’s feelings appropriate to the content of his/her thoughts?
Appropriate Inappropriate Other
I. Speech
1. Rate
Normal Slow Fast
2. Volume
Normal Loud Soft
3. Articulation
Normal Slurred Stuttering
4. Quantity
Appropriate Talkative Uncommunicative
5. Unusual Qualities
None Monotone Pressured Exaggerated Sing Song
Childish Other
J. Risk to Self or Others
1. Suicidality
Patient Denies Ideation Plan Means Prior Attempt
Comment: Date of prior attempt(s):
2. Homicidality
Patient Denies Ideation Plan Means Prior Attempt
Comment: Date of prior attempt(s):
3. Other Risk Behaviors (explain:)
Patient Denies Ideation Plan Means Prior Attempt
Comment: Date of prior attempt(s):
IX. Alcohol/Substance Use:
Patient Reports: None used Social/Moderate use Some Misuse Abuse
If either the “Some Misuse” or “Abuse” box is checked, a copy of the Substance Usage Addendum must be attached to this form or addressed in the narrative Intake Evaluation.
Tobacco Use: Patient Acknowledges Patient Denies
Frequency: Type of tobacco:
X. Clinical Impressions and Treatment Recommendations: (Include coordination of care)
XI. Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Current / Highest in Past Year
Therapist’s Signature (including credentials):
Date Signed:
Supervisor’s Signature (including credentials):
Date Signed:
(Optional) Clinical Supervisor or Collaborative Reviewer’s Signature (including credentials):
Date Signed:

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