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Intake Assessment
Ashton (Ash) Mason
Department of Counseling Education, MidAmerica Nazarene University
COUN 6523: Mental Health Intervention and Prevention
Professor Dembowski
April 16, 2022
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The Clinical Intake Assessment
The clinical intake assessment is a tool used to gain pertinent information that will be
used to build a case conceptualization in order to indicate proper and efficient treatment for our
client. Case conceptualizations “increases the potential for correctly identifying the causes and
effects involved in clients’ problems, which is what leads to effective interventions” (Meier,
2003, p. 14). This case conceptualization will include a detailed intake interview which will then
be used to create a provisional diagnosis, documenting predisposing, precipitating, and
perpetuating factors in the clients life, a case formulation, and a treatment plan. Ms. Rose
presented to this interview with a neutral affect and appeared to be completely oriented. As well,
she was neatly and properly groomed.
Chief Complaint
Client, Ms. Rose, is a 30-year-old female who presented to treatment indicating feelings
of depression over the course of her life, with some points in her life being more severe than
others. Symptoms specifically began around the age of 13 following the loss of her mother. Due
to depression, she also reported an interruption in her pleasure and interest in life in terms of her
romantic relationship, intimacy with her ex-partner, and in her work life. Ms. Rose desired to
engage in a “normal” relationship.
In addition to the above, Ms. Rose reported that her father has fallen ill and she was
uncertain regarding how to move forward in his care. Ms. Rose desired to reduce anxiety and
depression levels surrounding the care of her father and anticipates setting boundaries with him
as they worked through conflict and his continued care, as evidenced by seeking out her family
doctor and being medication compliant with Zoloft.
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Biopsychosocial History
Ms. Rose was a 30-year-old single female born in Minnesota on June 19, 1985. She
reported inconsistent sleep patterns in recent days and relationship problems with her now
former boyfriend. She noted a depressive history in her deceased mother that would include her
mother being unable to leave her bed or tend to her family. Around the age of 13, Ms. Rose’s
mother passed away which led to household expectations shifting to Ms. Rose. Following the
loss of her mother, Ms. Rose’s father began drinking and committed domestic violence against
Ms. Rose.
Ms. Rose currently takes Zoloft for depression as prescribed. Ms. Rose noted that there
are thyroid problems within her family, but is not certain which family members they reside in or
their severity. Ms. Rose’s father had recently fallen ill with an unknown illness, and she found it
to be difficult to discern the level and types of care he needed. Ms. Rose reports that despite the
low seasons, she has not and did not currently have suicidal or homicidal ideation, intent, or
means.
Nuclear Family
Ms. Rose does not have any children or roommates. Her father was in her life as an
individual who needed consistent care, but did not live with her.
Family of Origin
Ms. Rose’s mother passed away at the age of 33 from health related concerns. Prior to her
death, she was a school teacher and had obtained her bachelor’s and master’s degree in
education. Although she had times of “feeling down” that impacted her ability to function, she
did not have any history of mental health diagnosis or substance use.
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Ms. Rose’s father is a 50-year-old accountant. He has obtained a bachelor’s degree in
business and a master’s degree in accounting. He has been healthy throughout his life but just
recently began experiencing health difficulties which require care throughout the day. He did not
drink until after the death of his wife, but stopped drinking shortly after a domestic abuse
incident.
Ms. Rose reported having a steady and healthy relationship with her mother and felt that
her mother was “the only person that really cared about me.” She also reported that her mother
was difficult to connect to during times that her mother felt down. Ms. Rose reported that she
and her father maintained a healthy relationship prior to her mother’s death, but following the
death, their relationship became strained. She reportedly struggles with her and her father’s
relationship now that he has fallen ill. Ms. Rose recalled that members of her family had thyroid
problems, but was unable to provide further information.
Medical History
Ms. Rose reported that she has been eating less over the last couple of weeks prior to our
interview. She also reported difficulty with falling asleep. Ms. Rose reports that despite being
typically active in the past, she has struggled to motivate herself to work out. Ms. Rose indicated
that over the last 6 months, she has experienced headaches and weight loss. In her routine
physical, she is reportedly healthy, with the only concerns being related to depression. Ms. Rose
currently takes 50 mg of Zoloft as prescribed for depressive symptoms.
Educational and Employment History
Ms. Rose attended a well-known University to obtain her bachelor’s degree in education
before going on to earn a master’s degree in education and maintained a GPA of 3.75 while
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doing so. She currently works in an urban city high school setting and loves her job. She has
worked at this school for 7 years and aims to be a principal at some point.
Mental Health Treatment History
Ms. Rose reported that she has sought counseling on 3 previous occasions due to feelings
of depression without a specific precipitating event. She reported that each occasion occurred
with varying levels of frequency and duration. Following the death of her mother, her doctor
recommended she seek therapy and she did so. Ms. Rose does not currently receive services
from any other professional outside of her primary care physician. This physician sees her for
general health as well as depressive symptoms.
Social and Daily Activities
Ms. Rose reported that she spends time with other teachers as friends and enjoys their
company. She typically spends 3-4 evenings going out with friends after work and enjoys
attending concerts, working out, and going out for coffee. She reported that her depressive
feelings placed a strain on her friendships and social life. Ms. Rose reported that she is a
Christian who attends church weekly and prays to God daily. She reported that she is currently
looking for a new church due to her prior church's approach to her mental health.
Current DSM-5 Diagnosis:
Considering the loss Ms. Rose faced accompanied with the trauma surrounding, Ms.
Rose presented with F43.8 other specified trauma and stressor related disorder—persistent
complex bereavement disorder (Morrison, 2014, p. 289).
This diagnosis is evidenced by the following:
1. Indefinitely yearning/longing for the deceased
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2. Preoccupation with the circumstances of the deceased’s death
3. Intense sorrow and/or distress that does not improve over time.
4. Difficulty trusting others
5. Depression
6. Detachment and/or isolation
7. Difficulty pursuing interests or activities
8. Persistent feelings of loneliness or emptiness
9. Impairment in social, occupational or other areas of life (Wakefield, 2013, p. 172).
Case Formulation
The intent of this case formulation is to look at the clients sequential patterns of their
story, external emotions, subtle emotions, discontinuities within their story, and singularities in
patterns of speech, emotions, or story. “First, a formulation must be comprehensive, accounting
for everything the therapist knows about the patient thus far. Second, it should be coherent,
connecting as accurately as possible all of the patient’s communications and behaviors. Third, it
should be explicative; that is, it clarifies the hidden logic of the communications and behaviors
the patient displays during a session or a period of her/ his therapy. The formulation must clearly
interconnect the different life narratives and different interactional patterns with the therapist and
other people. Fourth, a formulation needs to explain the patient’s reactions to the therapist’s
communication/behavior. Fifth, the formulation needs to be specific; that is, it clearly ties the
pathogenic beliefs to the therapy goals and explain how they are inhibiting the patient from
pursuing or attaining these goals. Also, it should include a specific assessment of the way the
patient will test the therapist.” (Gazzillo et al., 2021, p. 121)
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Predisposing Factors
Ms. Rose had the predisposing factors of her mothers loss, her fathers domestic violence
and alcoholism, and having to grow up far too soon due to taking over the household
responsibilities. As well, her mother suffered with depressive episodes for Ms. Roses early
childhood. For the majority of her childhood, Ms. Rose only had her mother that she connected
with and felt understood by. She had no other adults she connected with on a significant level.
She and her fathers relationship became strained and abusive following the death of her mother.
Ms. Rose had a family atmosphere that she described in a conflicting way of affectionate, close,
angry, distant, cold, neglectful, and rigid. In addition to her home environment being conflictual
while growing up, Ms. Rose had a significant cycle of romantic relationships ending due to Ms.
Rose not being able to maintain the relationship. Finally, Ms. Rose’s father was strict in
upbringing and refused to allow Ms. Rose to explore dating as a teenager.
Precipitating Factors
Ms. Rose’s precipitating factors preceding our interview together included the loss of her
romantic relationship due to her poor mental health and inability to invest in their relationship,
her father falling ill in recent days and the confusion that surrounds his care and well-being, and
the response of her church to her depressive season. Each of these factors placed a new level and
type of stress on Ms. Rose that led to more significant depression.
Perpetuating Factors
Ms. Rose’s perpetuating factors included living alone, the ending of her relationship, and
her father’s illness. As well, she had a fairly limited support system that was sustained by her
work relationships.
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Initial Treatment Plan
Ms. Rose’s treatment plan for unresolved grief is as follows:
● Long-term goal: Resolve the loss, reengaging in old relationships and initiating new
contact with others.
○ Short-term objective: Participate in a therapy that addresses issues beyond grief
that have arisen as a result of the loss.
■ Therapeutic intervention: Assess for whether the client evidences a more
severe clinical syndrome secondary to the loss, and conduct or refer to an
appropriate evidence based therapy.
○ Short-term objective: Reengage in activities with family, friends, coworkers, and
others.
■ Therapeutic intervention: Promote behavioral activation by assisting the
client in listing activities that she previously enjoyed but have not engaged
in since experiencing the loss and then encourage reengagement in these
activities (Berghuis et al., 2021, p. 206).
This treatment plan is intended to increase Ms. Rose’s awareness of the grief, and to
begin to come to a sense of resolve within herself regarding the loss of her mother and the loss of
her childhood. As she does so, the intent is that she would begin to build significant and intimate
relationships with others, and that her depressive symptoms would begin to lessen. At which
point, ideally Ms. Rose would begin to reengage with the activities she once loved, and find new
activities she currently finds great pleasure in.
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Conclusion/Referrals/Network Building
It is recommended that Ms. Rose continues to be medication compliant, and asks her
physician for a psychiatrist referral. It is also recommended that Ms. Rose participates in
individual psychotherapy twice per week while incorporating Gestalt therapy for empty chair
work. The intent of incorporating empty chair and psychotherapy is to notice the patterns in
childhood and to name the withdrawal of her mother from her life (Erford, 2019, p. 63). It is also
recommended she participates in group grief therapy once per month with an emphasis on
complex bereavement. Ms. Rose is recommended to begin keeping a positivity journal with the
intent of beginning to recognize the beautiful and hopeful pieces of her life. Ms. Rose is also
recommended to begin working with a social worker in order to determine the best course of
action for the care of her father.
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References
Berghuis, D. J., Peterson, L. M., & Bruce, T. J. (2021). The complete adult
psychotherapy treatment planner (6th ed.). John Wiley & Sons.
Erford, B. T. (2019). 45 techniques every counselor should know (3rd ed.).
Pearson.
Gazzillo, F., Dimaggio, G., & Curtis, J. T. (2021). Case formulation and
treatment planning: How to take care of relationship and symptoms
together. Journal of Psychotherapy Integration, 31(2), 115-128.
https://doi.org/10.1037/int0000185
Meier, S. T. (2003). Bridging case conceptualization, assessment, and
intervention. SAGE.
Morrison, J. (2014). DSM-5 made easy: The clinician's guide to diagnosis
(5th ed.). Guilford Publications.
Wakefield, J. C. (2013). DSM-5 grief scorecard: Assessment and outcomes
of proposals to pathologize grief. World Psychiatry, 12(2), 171-173.
https://doi.org/10.1002/wps.20053