Wildwood Case Management Unit
Intake Assessment (Social History) Form
Client Name:
Date of Birth:
Date of Assessment:
Presenting Problem (functional impairment, symptoms, background)
Current Client Involvement with Other Agencies
Agency/Person
Phone
Service
Date
Assessment of Life Circumstances or Changes in the Following Areas
Family:
Social:
Support:
Current Medications
Name/Dosage:
Side effects:
Medication allergies:
Prescribed by:
Relationship Risk Factors
Is client safe at home? Yes
No
Does client feel threatened in any way?
Yes
No
If Yes, describe:
Has client been abused in any way?
Yes
No
If Yes, complete the following:
Check all that apply:
Physical
Emotional
Sexual
Relationship of perpetrator to client:
Legal action taken:
Does client have a safety plan?
Yes
No
Needs shelter?
Yes
No
Needs protection from abuse order?
Yes
No
1
Client’s Legal History
Suicide/Homicide Evaluation
Client’s self-rating of suicide risk:
1-none
2-slight
3-moderate 4extreme/immediate
Client’s self-rating of becoming violent:
1-none
2-slight
3-moderate 4extreme/immediate
Client’s self-rating of homicide risk:
1-none
2-slight
3-moderate 4extreme/immediate
Mental Status Exam
Appearance
age appropriate
well groomed
Orientation
person
place
time
disheveled/unkempt
other
situation
Behavior/Eye Contact
good
limited
avoidant
none
relaxed/calm
slumped posture
tense
tics
tremors
Motor Activity
mannerisms
bizarre
motor retardation
restless
rigid
agitated
catatonic behavior
Manner
appropriate
trusting
cooperative
inappropriate
withdrawn
seductive
playful
evasive
guarded
sullen
passive
defensive
hostile
manic
demanding
inappropriate boundaries
Speech
normal
incoherent
pressured
too detailed
slurred
slowed
impoverished
halting
neologisms
neurological language disturbances
Mood
appropriate
expansive
Affect
broad
depressed
tearful
irritable
blunted
anxious
constricted
2
euphoric
flat
labile
fatigued
excited
angry
anhedonic
Sleep
good
fair
poor
terminal insomnia
Appetite
good
fair
poor
increased
decreased
initial insomnia
increased
decreased
weight gain
middle insomnia
weight loss
Thought Process
logical and well organized
illogical
flight of ideas
circumstantial
loose
associations
rambling
obsessive
blocking
tangential
spontaneous
perseverative
distractible
Thought Content
delusions
paranoid delusions
distortions
thought withdrawal
thought insertion
thought broadcast
magical thinking
somatic delusions
ideas of reference
delusional guilt
grandiose delusions
nihilistic delusions
ideas of inference
Perceptions/Hallucinations
illusions
hallucinations
depersonalization
derealization
Suicide Risk
none
slight
plan (describe:
moderate
)
significant
extreme
no plan
Violence risk
none
slight
plan (describe:
moderate
)
significant
extreme
no plan
Judgment
intact
age appropriate
severe
impulsive
Insight
intact
limited
very limited
fair
understands personal role in problems
Sensorium
alert
drowsy
stupor
above average
none
obtundation
Memory
intact
impaired
immediate recall
amnesia (type of amnesia:
)
Intelligence
average
immature
impaired
remote
3
moderate
aware of current disorder
coma
below average
mild
unable to establish
Interviewer Summary of Findings (add details where appropriate)
Substance Use/Abuse
Type
Amount
Used
How Taken
Duration
Frequency
Tobacco
Alcohol
Illicit Drugs
Prescription
Drugs
OTC Drugs
Other
Experiencing
Withdrawal
Blackouts
Hallucinations
Vomiting
Severe Depression
DTs and Shaking
Seizures
Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No If yes, describe:
Patterns of Use
Uses more under stress
Continues use when others have stopped
Has lied about consumption
Has tried to avoid others while using
Has been drunk/high for several days at a time
Neglects obligations when using
Usually uses more than intended
Needs to increase use to become intoxicated
Has tried to hide consumption
Sometimes uses before noon
Cannot limit use once begun
Failed to keep promises to reduce use
Yes
Yes
Yes
Yes
Yes
Yes
Describe attempts to stop:
4
Yes
No
No
No
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
No
No
Date of last
use
Describe circumstances that usually lead to relapse:
Is client involved in AA/NA?
Yes
No
Client Requests, Goals, Expectations
Clinical Summary (Pull together information you have collected and summarize, identifying
possible relationships, conditions, and causes that may have lead to current situation.)
Impressions
Recommendations
Diagnostic Impression
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Case Manager Signature:
Date:
5