FAMILY SERVICE ASSOCIATION
3073 ENGLISH CREEK AVENUE, EGG HARBOR TWP., NJ 08234
PHONE (609) 569-0239 * FAX (609) 569-1942
EAP INTAKE ASSESSMENT
CLIENT NAME:
CLIENT IS:
EMPLOYEE
AGENCY/ORGANIZATION:
DATE OF CALL:
DEPENDANT
BOTH (COUPLE’S COUNSELING)
JOB POSITION:
MANAGERIAL
NON-MANAGERIAL
REFERRAL TYPE:
SELF
SUPERVISORY
FAMILY MEMBER
INITIAL VISIT:
YES
NO
IF NO, WHEN DID THE LAST SET OF PREVIOUS EAP VISITS OCCUR?
IS CLIENT CURRENTLY UNDER PHYSICIAN’S CARE?
YES
EDUCATION
OTHER:
NO
ELEMENTARY/MIDDLE
SPECIAL ED
HIGH SCHOOL
DID NOT COMPLETE HS
GED
TRADE SCHOOL
COLLEGE
2 YR ASSOC.
4 YR COLLEGE
POST BACHELORS DEGREE
EMPLOYMENT
SOURCE OF INCOME:
EMPLOYMENT
SPOUSE OR FAMILY
SSI/SSD
WORKER’S COMP
INCOME FROM UNEMPLOYMENT
NOT EMPLOYED, MO/YR LAST WORKED: ____________________________
PHYSICAL HEALTH PROBLEMS
DIABETES
HEART DISEASE
ASTHMA/RESPIRATORY
ALLERGIES
KIDNEY/URINARY
HIGH BP
CHOLESTEROL
GASTRO INTESTINAL
HEPATITIS
MEMORY
AUTO IMMUNE DISEASE
NONE
OTHER:
LIST ALLERGIES & MEDICATION ALLERGIES:
HISTORY OF THE FOLLOWING:
DATE/YEAR/DETAILS
SURGERIES
YES
NO EXPLAIN:
ACCIDENTS
YES
NO EXPLAIN:
FRACTURES
YES
NO EXPLAIN:
BRAIN INJURIES
YES
NO EXPLAIN:
HOSPITALIZATIONS
YES
NO EXPLAIN:
OTHER:
LIST CURRENT MEDICATIONS OR CHECK IF NONE:
MEDICATIONS
DOSAGE
FREQUENCY
LIST PAST PSYCHIATRIC MEDICATIONS AND SIDE EFFECTS
LIVER
PRESCRIBER AND SIDE EFFECTS
CHECK IF NONE
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CLIENT NAME:
DATE OF BIRTH:
PSYCHIATRIC HISTORY
LIST PAST PSYCHIATRIC HISTORY, OUTPATIENT COUNSELING, PARTIAL CARE, HOSPITALIZATIONS WITH DATES OR:
NONE
SUBSTANCE USE/ABUSE HISTORY
CURRENT DENIED YES
EXPLAIN & LIST: DAILY AMOUNT/WEEKLY AMOUNT/OCCASIONALLY/TIME IN RECOVERY
CAFFEINE
TOBACCO
ALCOHOL
MARIJUANA
COCAINE
PILLS
OTHER:
TREATMENT
OUTPATIENT/IOP
INPATIENT
PARTIAL
AA/NA
IDRC
NO TREATMENT
LEGAL OR FINANCIAL PROBLEMS AS A RESULT OF DRUG USE:
DENIED
YES EXPLAIN:
FAMILY MENTAL HEALTH HISTORY
FATHER SIBLINGS GRANDPARENTS DENIED
MOTHER
COMMENTS
ANXIETY/PANIC
DEP/BIPOLAR
SCHIZOPHRENIA
ANGER
SUICIDAL BEHAVIOR
HOSPITALIZATION
SUBSTANCE ABUSE
PLEASE DESCRIBE YOUR FAMILY BACKGROUND, RELATIONSHIPS WITH PARENTS, SIBLINGS, CONFLICTS, CRISES:
LIST CURRENT FAMILY MEMBERS/LIVING SITUATION. WHO YOU LIVE WITH:
MARITAL STATUS:
MARRIED
DESCRIBE CURRENT RELATIONSHIP:
DIVORCED
WIDOWED
SINGLE
I LIVE ALONE:
LIVING TOGETHER
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CLIENT NAME:
DATE OF BIRTH:
CLIENT MENTAL HEALTH PROBLEM CHECKLIST
PRESENT
SEVERITY: 1=MILD
5=SEVERE
0
1
2
3
4
5
WHEN IT BEGAN/HOW LONG
INTAKE ONLY
# PATIENTS SEEN
# OF OUTPATIENT SESSIONS
AVERAGE # OF EAP SESSIONS
AVERAGE # OF ALL SESSIONS
PRESENTING PROBLEMS (BY # AND %)
DRUG & ALCOHOL (PATIENT/EMPLOYEE)
DEPRESSION
STRESS
EMPLOYMENT
DRUG & ALCOHOL (FAMILY /DEPENDENT)
ANXIETY
MARITAL
ADJUSTMENT DISORDER
EXPLOSIVE DISORDER
ANXIETY/DEPRESSION
CONDUCT DISORDER
FAMILY ISSUES
PTSD
PSYCHOSIS
PANIC DISORDER
COMPULSIVE
BIPOLAR DISORDER
ADD
SUICIDAL
SEXUAL
PERSONALITY DISORDER
LEARNING DISORDER
EATING DISORDER
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