Clinical Intake Outline—Child/Adolescent
Patient Identification
Child/Adolescent Name:
Medical Record #:
Date of Birth:
Date(s) of Assessment:
Person(s) Interviewed and relation to child:
Clinician:
Clinician # (if applicable):
Instructions to Clinician: Before conducting the clinical interview, carefully review the client information form and other
application materials. Expand and clarify the information gathered from those materials on this form. It is not necessary to copy
information from other sources onto this document but to record new information and clarification of other materials.
Reason for Referral:
Referral source:
Why seeking treatment/assessment at this time?
List major problems/reasons for referral, in parents’ own words/terms (to be operationalized as specific behavioral
targets/objectives on following pages):
http://www.smbs.buffalo.edu/CENTERS/adhd/default.php
Intake Outline—Page 2
History of Problems and Treatment (from client information form; query for accuracy and expand if necessary; e.g., When first
diagnosed with ADHD?)
Personal and Social Information
1.
Who lives in the home?:
a. Who is/are the primary caretaker/s?
b. Who is/are the primary disciplinarian/s?
c. What are the interactions like between the child and other adults in the home? (including stepparents, grandparents,
boyfriends, etc.)
d. What are the responsibilities of the other adults in the home for the child?
School Information (The information in this section should come primarily from the client information form, school records, and
meeting with the child’s teacher/s. Information that is incomplete from the application packet should be queried in this section.)
1.
Current placement of child in school (get information from client information form and rest of application packet)
Grade:
# children in class:
Does the child have a current IEP or 504 plan? (describe/attach copy)
Nature of special class placement:
Describe how placement occurred
How well is the child doing in the current classroom?
# teachers/aides:
Intake Outline—Page 3
2.
History of school placement [get information prior to intake from application packet (child's school schedule, CBCLs)]
Grades retained:
Typical grades:
Ever expelled or suspended? Describe circumstances:
In special placement in the past? Describe how placement occurred and how long in placement:
3.
Testing [get information from application packet (e.g., CBCLs)] and get signed release to obtain results if parent does not bring
copy.
Any intelligence/achievement testing?
What tests have been given and dates in the past?
Most recent date of intelligence or achievement testing:
Where tested?
What were results?
4.
Current teacher/school report (Has teacher, principal, counselor, etc. complained to parents of or noted a need for improvement in
child's behavior or academic performance? Describe complaints; consult impairment ratings etc. for information)
Intake Outline—Page 4
5.
School's child management procedures (e.g., school's punishments for inappropriate behavior, and reward programs for good
behavior; how have programs worked?)
Use now
Used in
Outcomes
past
Consistent classroom rules and structure:
Praising appropriate behaviors/ignoring
minor inappropriate behaviors:
Instructional modifications:
Daily report card (DRC):
Homework assignment book:
"If...then" contingencies:
Point or token reward system:
Response-cost system:
Group or classwide contingencies:
Time out:
School-wide programs:
6.
Parent Report of teacher/school assets and liabilities
a. Teacher’s motivation/willingness for involvement in program
b. Principal/other administrator’s motivation/willingness for involvement in program
c. Relationship between the teacher/school administration and parents
d. How often do the parents and teacher/administration communicate:
By note:
By phone:
7.
Face-to-face?
Teacher Report of teacher/school assets and liabilities
a. Teacher’s motivation/willingness for involvement in program
b. Principal/other administrator’s motivation/willingness for involvement in program
c. Relationship between the teacher/school administration and parents
d. How often do the parents and teacher/administration communicate:
By note:
By phone:
Face-to-face?
Intake Outline—Page 5
Presenting Problems (complete one page for each problem; continue on back if necessary). Begin by giving a brief ABC
explanation of behavior and explain that you will be asking about antecedents, behaviors and consequences, all defined very
specifically and objectively.
Problem (define specific behavioral target from previous page):
When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by
someone else)
How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?
-Home
-School
-With peers
-Other (describe)
What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person,
setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time,
settings, people, etc. (e.g., preset, cyclic)?
What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify
consequences and what have been the results? How consistent have the parents’ reactions been?
What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the
problem? What are short-term and long-term consequences?
No Problem
Does not need intervention
Extreme Problem
Definitely needs intervention
Intake Outline—Page 6
Problem (define specific behavioral target from previous page):
When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by
someone else)
How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?
-Home
-School
-With peers
-Other (describe)
What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person,
setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time,
settings, people, etc. (e.g., preset, cyclic)?
What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify
consequences and what have been the results? How consistent have the parents’ reactions been?
What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the
problem? What are short-term and long-term consequences?
No Problem
Does not need intervention
Extreme Problem
Definitely needs intervention
Intake Outline—Page 7
Problem (define specific behavioral target from previous page):
When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by
someone else)
How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?
-Home
-School
-With peers
-Other (describe)
What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person,
setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time,
settings, people, etc. (e.g., preset, cyclic)?
What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify
consequences and what have been the results? How consistent have the parents’ reactions been?
What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the
problem? What are short-term and long-term consequences?
No Problem
Does not need intervention
Extreme Problem
Definitely needs intervention
Intake Outline—Page 8
Problem (define specific behavioral target from previous page):
When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by
someone else)
How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?
-Home
-School
-With peers
-Other (describe)
What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person,
setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time,
settings, people, etc. (e.g., preset, cyclic)?
What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify
consequences and what have been the results? How consistent have the parents’ reactions been?
What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the
problem? What are short-term and long-term consequences?
No Problem
Does not need intervention
Extreme Problem
Definitely needs intervention
Intake Outline—Page 9
Problem (define specific behavioral target from previous page):
When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by
someone else)
How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?
-Home
-School
-With peers
-Other (describe)
What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person,
setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time,
settings, people, etc. (e.g., preset, cyclic)?
What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify
consequences and what have been the results? How consistent have the parents’ reactions been?
What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the
problem? What are short-term and long-term consequences?
No Problem
Does not need intervention
Extreme Problem
Definitely needs intervention
Intake Outline—Page 10
Current treatment (see client information form, query for confirmation, clarification, and expand if necessary)
Psychoactive medication
Prescribing physician:
Medication and dosage
Date last seen:
Condition received for:
# times taken
each day
# days/week taken
School-days 7 days
School days + as needed
School-days 7 days
School days + as needed
School-days 7 days
School days + as needed
School-days 7 days
School days + as needed
School-days 7 days
School days + as needed
Any medication side effects?
Psychosocial (describe nature of treatment in detail):
Classroom interventions (describe nature of interventions in detail, including parents’ role):
School psychologist/counselor:
Other:
How long on this
dosage?
Intake Outline—Page 11
Parents’ child management procedures:
a. Describe parents’ typical punishment for inappropriate behavior and rewards for good behavior (include information on
consistency across time, settings, and parents). Complete table and expand:
Use now
Used in
How does/did it work?
past
House rules
Praising appropriate behaviors/ignoring
minor inappropriate behaviors
Use of commands
Use of reprimands
Loss of privileges
Daily report card (DRC):
"If...then" contingencies
Spanking/physical punishment
Point or token reward system:
Response-cost system:
Time out:
b. Can the parent and child/adolescent communicate effectively with each other? How well can they solve problems together
without getting angry?
c. How well does the parent monitor or keep track of the child's/adolescent’s whereabouts, including what the child is doing,
who the child is with, where the child is?
d. What is the parents’ background with behavioral parent programs - previous parent training classes, reading, etc.? What are
the parents' main sources of parenting knowledge?
Motivation for treatment, willingness to change (separately for child, mother, father, etc.):
Intake Outline—Page 12
How does everyone in the home get along with one another? (include relevant individuals in the child’s home and each set of custodial
parents/homes)
a. Parents (Do parents agree on discipline strategies? Are parents sharing care of the child in a mutually satisfactory manner? Is
there frequent marital conflict?):
b. Mother/s and child:
c. Father/s and child:
d. Siblings and child:
e. Friends and child:
f. Others (specify):
Are the biological parents divorced?
a.
How long since the divorce? (see client information form)
Who has custody of child; what are custody arrangements:
-legal?
–practical? (e.g., how often does the child see each parent)?
b.
What is the degree of contact with the parent not in the home?
c.
Does this parent argue with the interviewed parent regarding appropriate discipline and expectations for the child? Do
the parents get along with each other or is there conflict? Are transitions from one parent's home to another difficult?
(see client information form for some information)
Intake Outline—Page 13
d. Has the child experienced a subsequent divorce? (If so, repeat questions c-d for that parent)
Does child/adolescent have his/her own room or does he/she sleep with others?
What is the physical environment of the home? (e.g., apartment or house? Is there a yard to play in? Where does the child play?)
Child-parent interactions
a. How much time does each parent spend with the child?
b. Do the parent and child get to spend some enjoyable time together each week?
Social Stressors
a. Financial (include information about family financial status)
b. Work-related
Parents’ occupations and work hours (include information about day care arrangements):
c. Transitions (How many different parent figures has the child had? How many times has the child moved? Most recent
transition?)
d. Relatives
e. Medical
f. Other (include regular commitments/obligations of parents and hours (i.e., school, troop leader, care of elderly relative,
volunteer work)
Intake Outline—Page 14
Rating of Overall Stressor Severity (DSM IV)
1
None
2
Mild
3
Moderate
4
Severe
5
Extreme
6
Catastrophic
7
Unspecified
Social Supports (relatives, neighborhood, vocational)
Medical and Developmental History (review client information form and health history questionnaire; the clinician should inquire
to clarify that information is correct and to get detailed information about anything abnormal or problems reported)
1.
Pregnancy (see health history questionnaire)
2.
Developmental milestones (walk, talk, toilet trained)
3.
Hospitalizations/surgeries (see client information form and health history questionnaire)
4.
Medical problems (include any recent symptom complaints such as headaches, stomachaches, etc.; see client information
form and health history questionnaire)
5.
Medications (only medications not listed for ADHD treatment)
6.
Allergies to medicine or adverse drug reactions (see application form and health history questionnaire)
Intake Outline—Page 15
7.
Childhood illnesses (see application form and health history questionnaire)
8.
Enuresis/encopresis (see item 108 on parent CBCL)
9.
Tics (unusual movements) (see item 46 on parent CBCL and health history questionnaire; make sure that parents understand
this question by defining or demonstrating if necessary)
10.
Seizures or spells (do they interrupt behavior) (see client info. form and health history questionnaire)
11.
Eating disorders (obesity, anorexia, bulimia)
12.
Physical limitations (see client information form)
13.
Special diet
14.
Vision/hearing problems (if tested, when? see health history questionnaire)
15.
Confirm physician's name, phone number (how long/often have they been seeing this physician and any previous physicians)
(see page 2 of the application form)
Intake Outline—Page 16
If appropriate, explore the following in more detail (current and past):
Sexual problems
Sleep problems
Post-traumatic stress disorder
Adjustment disorders
Sexual activity
Trouble with the law
Physical or sexual abuse
Suicidal ideation and behavior
Tobacco, alcohol, or other drug use/abuse
Intake Outline—Page 17
Functioning Level (Axis V from DSM IV)
Past GAF Score:
Highest level of functioning in the past year for at least a few months
Current GAF Score:
Level of functioning at the time of the assessment
Significant Family Medical and Psychiatric History
Clinician is responsible to ensure comprehensiveness, accuracy, and limitations of the information provided on the client
information form. Information on the client information form must therefore be reviewed, clarified, and confirmed. In
addition, the clinician is responsible for documenting the following:
# of biological mother's sister(s):
# of biological mother's brother(s):
# of biological father's sister(s):
# of biological father's brother(s):
Impact of Patient's Problems on the Child/Adolescent, the Family, the School, and Other Support Systems
(e.g., effects of problem on the family as a unit, e.g., on child's relationships with siblings, parents, on parents' relationship with one
another)
Mental Status of Child and Parents (clinician observations)
1.
Appearance and General Behavior
2.
Mood and Affect
3.
Rate and pattern of speech and thought
4.
Content of speech and thought
5.
Perception
6.
Cognitive functions
7.
Insight into problems
Intake Outline—Page 18
Patient/Family Strengths
Recommendations for Further Evaluation
Additional history (specify wherever possible the sources of additional history)
Diagnostic assessments (recommendations for laboratory studies, neuropsychological testing, educational needs, etc.)
Problem list and recommendations (note each area of concern followed by proposed treatment recommendations)
DSM-IV Multiaxial Diagnostic Formulation
I. Clinical Disorders, Other conditions that may be a focus of clinical attention
II. Personality Disorders, Mental Retardation
III. General Medical Conditions
IV. Psychosocial and Environmental Problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems
V. Global Assessment of Functioning