Case Study. Intake form
Student Name:
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Adolescent Intake Form
ADOLESCENT/CLIENT’S INFORMATION
|
NAME:
|
|
AGE:
|
|
GENDER
|
|_| Male |_| Female
|
|
RACE/ETHNICITY
|
|_| Caucasian/White |_| Hispanic |_| Native American
|_| African American/Black |_| Asian |_| Biracial |_| Other
|
|
who referred THE CLIENT?
|
|_|Self |_| Parent/Family Member |_|Teacher |_|Friend |_|Other: _____________
|
|
What problems/ISSUES DOES THE CLIENT PRESENT WITH?
|
|
WHEN DID THESE CONCERNS BEGIN?
|
|
Is Treatment Court Ordered?
|
|_|Yes |_|No If yes, why:_____________
|
|
Employment information:
|
|_| Full-time Student |_| Part-time Student |_| Employed |_| N/A
Name of Employer: ____ Job Title:______
|
|
LEGAL HISTORY:
|
Has the child been charged with a crime? |_| Yes |_| No
Is the child on probation? |_| Yes |_| No
If yes, please explain:
|
SUBSTANCE USE HISTORY:
|_| NONE |_| Alcohol |_| Other substance use: ________________
Attended alcohol/drug abuse treatment: |_|Yes |_|No
Has the child been told that they have an alcohol/drug problem: |_|Yes |_|No
SCHOOL FUNCTIONING
|
High School Grade
|
|
Past / Present truancy issues
|
|
Yes |_| No |_|
|
|
Expulsions
|
Yes |_| No |_| If yes, explain number and reason(s): __________
|
|
Suspensions
|
Yes |_| No |_|
|
Repeat Grades
|
Yes |_| No |_|
|
Any special accommodations made for student?
|
|_| No |_| 50
4
Plan |_| Special Education / IEP
If yes, explain:
SOCIAL, PLAY AND RECREATION
|
Describe the child’s recreational interests (if any).
|
|
Briefly describe significant relationships (many/few friends, best friend, romantic relationships, etc.)
|
Caregiver/HOUSEHOLD information:
|
Who is primary caregiver of the adolescent? |_| Parent |_| Other Relative |_| Guardian |_| OTHER
If other, explain:
|
|
Number of household members:
Who lives in the home with the child (parent(s), siblings, others, etc.
):
|
|
Who lives in the home with the child (parent(s), siblings, others, etc.
|
|
Brief description of living arrangements
|
|
Are there any custody/visitation arrangements? Please describe.
|
|
Describe the child’s family, cultural and religious connections.
|
Mental Health History:
|
|_| No previous therapy (Skip to next section of form)
|
|
|_| Outpatient Treatment
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
|
|
|_| Inpatient Treatment/Psychiatric Hospitalization
Previously hospitalized: |_| Yes |_| No |_| N/A Multiple Hospitalizations: |_| Yes ___________
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
|
|
Has the child experienced grief and or loss, or significant trauma? |_| Yes |_| No Explain: ___________
|
MEDICAL INFORMATION:
|
Does adolescent have a primary care physician?
|
Yes |_| No |_|
Visit/Checkup with PCP within the past 12 months: |_| Yes |_| No
Regular preventative health screens: |_| Yes |_| No
|
|
Currently Prescribed Medications
|
|_|
No |_| Yes
If Yes, identify medications: ______________
Has client been consistently taking medications as prescribed?
|_|
No |_| Yes
|
General Functioning: (Please check all that apply)
|_| Cheerful/happy mood most of the time |_| Extreme ups and downs in mood |_| Conflict with authority figures
|_| Sad or tearful most of the time |_| Irritability/anger |_| Stealing
|_| Feelings of hopelessness |_| Distinct periods of nonstop activity |_| Physical cruelty to animals
|_| Withdrawn behaviors |_| Exaggerated view of abilities |_| Physical aggression
|_| Difficulty thinking |_| Fast/rapid speech |_| Verbal threats to harm others
|_| Under active/sluggish behavior |_| Feels rested after 3-4 hours sleep/ night |_| Threat to kill with intent /plan
|_| Intentional self harm |_| Fearless/engaging in reckless activities |_| Lying
|_| Suicidal thoughts |_| Fearful of places, situations or people |_| Extreme conflict with siblings
|_| Suicide attempts |_| Worries about ____________________ |_| Running away
|_| Increased appetite |_| Decreased appetite |_| Poor social skills
|_| Nightmares |_| Inability to complete tasks |_| Inability to sustain attention
|_| Takes more than an hour to fall asleep |_| Sexual promiscuity |_| Overactive/hyperactive
behavior
|_| Night waking for longer than 30 minutes |_| Excessive masturbation |_| Easily distracted
|_| Hard to wake up in the morning |_| Intentional vomiting/purging |_| Difficulty concentrating
|_| Sleepwalking |_| Poor self-care/poor hygiene |_| Other: _____________
3/22/2021
4
3/22/2021
Is there anything else the client would like to share?
What theories and/or models from the book apply to this adolescent and help us understand this transitional time or reporting issue?
How could someone trying to help this adolescent use theories and research as noted in the text?
Discuss common relationship changes that occur in adolescence (parental, friendships and romantic), and compare/contrast to this adolescent’s relationships.
Discuss the typical influence of social environments relevant to adolescence to include the role of family, peers, culture, school. How does this compare to this adolescent’s experiences?
Complete the in-take form, being sure to include demographic detail about your patient that will provide a reference point for future seminars. Consider and list what models and theories help to understand this transitional time, as related to the reporting issue. What challenges does this present for the character?
Develop a paper to address the following questions:
1. How could someone trying to help this adolescent use theories and research as noted in the text? Use at least 2 major theoretical perspectives that are relevant to this adolescent.
2. In the report based on the adolescent’s age, discuss in depth the key biological and cognitive transitions that the adolescent might be experiencing? Be sure to address how biological changes influence adolescent cognition, emotions and behaviors. Be sure to explore adolescent decision making, abstract thought, and critical thinking. Would these affect the presenting issues/concerns?
Suggested Length – Two full pages, along with a separate reference page
Student Name:
Adolescent Intake Form
ADOLESCENT/CLIENT’S INFORMATION
|
NAME:
|
|
AGE:
|
|
GENDER
|
|_| Male |_| Female
|
|
RACE/ETHNICITY
|
|_| Caucasian/White |_| Hispanic |_| Native American
|_| African American/Black |_| Asian |_| Biracial |_| Other
|
|
who referred THE CLIENT?
|
|_|Self |_| Parent/Family Member |_|Teacher |_|Friend |_|Other: _____________
|
|
What problems/ISSUES DOES THE CLIENT PRESENT WITH?
|
|
WHEN DID THESE CONCERNS BEGIN?
|
|
Is Treatment Court Ordered?
|
|_|Yes |_|No If yes, why:_____________
|
|
Employment information:
|
|_| Full-time Student |_| Part-time Student |_| Employed |_| N/A
Name of Employer: ____ Job Title:______
|
|
LEGAL HISTORY:
|
Has the child been charged with a crime? |_| Yes |_| No
Is the child on probation? |_| Yes |_| No
If yes, please explain:
|
SUBSTANCE USE HISTORY:
|_| NONE |_| Alcohol |_| Other substance use: ________________
Attended alcohol/drug abuse treatment: |_|Yes |_|No
Has the child been told that they have an alcohol/drug problem: |_|Yes |_|No
SCHOOL FUNCTIONING
|
High School Grade
|
|
Past / Present truancy issues
|
|
Yes |_| No |_|
|
|
Expulsions
|
Yes |_| No |_| If yes, explain number and reason(s): __________
|
|
Suspensions
|
Yes |_| No |_|
|
Repeat Grades
|
Yes |_| No |_|
|
Any special accommodations made for student?
|
|_| No |_| 50
4
Plan |_| Special Education / IEP
If yes, explain:
SOCIAL, PLAY AND RECREATION
|
Describe the child’s recreational interests (if any).
|
|
Briefly describe significant relationships (many/few friends, best friend, romantic relationships, etc.)
|
Caregiver/HOUSEHOLD information:
|
Who is primary caregiver of the adolescent? |_| Parent |_| Other Relative |_| Guardian |_| OTHER
If other, explain:
|
|
Number of household members:
Who lives in the home with the child (parent(s), siblings, others, etc.
):
|
|
Who lives in the home with the child (parent(s), siblings, others, etc.
|
|
Brief description of living arrangements
|
|
Are there any custody/visitation arrangements? Please describe.
|
|
Describe the child’s family, cultural and religious connections.
|
Mental Health History:
|
|_| No previous therapy (Skip to next section of form)
|
|
|_| Outpatient Treatment
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
|
|
|_| Inpatient Treatment/Psychiatric Hospitalization
Previously hospitalized: |_| Yes |_| No |_| N/A Multiple Hospitalizations: |_| Yes ___________
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
|
|
Has the child experienced grief and or loss, or significant trauma? |_| Yes |_| No Explain: ___________
|
MEDICAL INFORMATION:
|
Does adolescent have a primary care physician?
|
Yes |_| No |_|
Visit/Checkup with PCP within the past 12 months: |_| Yes |_| No
Regular preventative health screens: |_| Yes |_| No
|
|
Currently Prescribed Medications
|
|_|
No |_| Yes
If Yes, identify medications: ______________
Has client been consistently taking medications as prescribed?
|_|
No |_| Yes
|
General Functioning: (Please check all that apply)
|_| Cheerful/happy mood most of the time |_| Extreme ups and downs in mood |_| Conflict with authority figures
|_| Sad or tearful most of the time |_| Irritability/anger |_| Stealing
|_| Feelings of hopelessness |_| Distinct periods of nonstop activity |_| Physical cruelty to animals
|_| Withdrawn behaviors |_| Exaggerated view of abilities |_| Physical aggression
|_| Difficulty thinking |_| Fast/rapid speech |_| Verbal threats to harm others
|_| Under active/sluggish behavior |_| Feels rested after 3-4 hours sleep/ night |_| Threat to kill with intent /plan
|_| Intentional self harm |_| Fearless/engaging in reckless activities |_| Lying
|_| Suicidal thoughts |_| Fearful of places, situations or people |_| Extreme conflict with siblings
|_| Suicide attempts |_| Worries about ____________________ |_| Running away
|_| Increased appetite |_| Decreased appetite |_| Poor social skills
|_| Nightmares |_| Inability to complete tasks |_| Inability to sustain attention
|_| Takes more than an hour to fall asleep |_| Sexual promiscuity |_| Overactive/hyperactive
behavior
|_| Night waking for longer than 30 minutes |_| Excessive masturbation |_| Easily distracted
|_| Hard to wake up in the morning |_| Intentional vomiting/purging |_| Difficulty concentrating
|_| Sleepwalking |_| Poor self-care/poor hygiene |_| Other: _____________
3/22/2021
4
3/22/2021
Is there anything else the client would like to share?
What theories and/or models from the book apply to this adolescent and help us understand this transitional time or reporting issue?
How could someone trying to help this adolescent use theories and research as noted in the text?
Discuss common relationship changes that occur in adolescence (parental, friendships and romantic), and compare/contrast to this adolescent’s relationships.
Discuss the typical influence of social environments relevant to adolescence to include the role of family, peers, culture, school. How does this compare to this adolescent’s experiences?
Complete the in-take form, being sure to include demographic detail about your patient that will provide a reference point for future seminars. Consider and list what models and theories help to understand this transitional time, as related to the reporting issue. What challenges does this present for the character?
Develop a paper to address the following questions:
1. How could someone trying to help this adolescent use theories and research as noted in the text? Use at least 2 major theoretical perspectives that are relevant to this adolescent.
2. In the report based on the adolescent’s age, discuss in depth the key biological and cognitive transitions that the adolescent might be experiencing? Be sure to address how biological changes influence adolescent cognition, emotions and behaviors. Be sure to explore adolescent decision making, abstract thought, and critical thinking. Would these affect the presenting issues/concerns?
Suggested Length – Two full pages, along with a separate reference page
