Documente Academic
Documente Profesional
Documente Cultură
Initial Assessment
Client
Name:
Intake Date(s)
DOB
I.
Identification Data (age, sex, year in school, major, marital status, living situation)
II.
A. Presenting Concerns(s)
1. Academic
7. Anxiety
2. Career
8. Alcohol/Substance Use
3. Relationship
9. Adjustment to School
4. Family
10. Physical Abuse
5. Medical/Somatic
11. Sexual Abuse
6. Depression
12. Eating/Weight
IV. Personal History (psychiatric treatment [if so, what did you like and what did you not like], medical treatment)
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V. Family History (size of family, any psychiatric treatment, medical history, suicide/homicide, drug/alcohol abuse)
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1. Orientation
___No
2. Behavior
___ Appropriate ___ Agitated ___ Psychomotor Slowing
___________ ______________________________
3. Memory (Intact)
Recent ___ Yes ___ No
Remote ___ Yes ___ No
4. Estimated Intellect
___ Below Avg. ___ Avg. ___ Above Avg.
5. Judgment
___ Appropriate ___Impaired
6. Affect
___ Appropriate ___ Inappropriate ___Labile
7. Mood
___ Euthymic
___ Depressed ___ Anxious ___Euphoric ___Irritable
8. Thought Process
___ Psychotic Symptoms
___ Delusions
___ Paranoia
___ Phobias
___ Obsessions
___ Worthlessness/Guilt
___ Suicidal thoughts
___ Homicidal thoughts
___ Appropriate
9. History of CNS trauma and seizure disorder
(head injury, loss of consciousness)
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Time Frame___________
4
poor
5
guarded
Noncampus
____ Hospital
____ Other Mental Health
____ Private Care
____ Drug/Alcohol
____ Other ________
Treatment Goals:______________________________________________________________________________________________
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Therapist_____________________________________________________
Date___________________________________
Date___________________________________