GRACE STREET SERVICES, LLC

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GRACE STREET SERVICES, LLC

Initial Intake/Assessment

Name of Clinician:___________________________________________________Intake Date:____________________________

Name of Client:______________________________________________________________DOB:____________________________

Reason For Treatment

__Current Concerns/Presenting Problem:___________________________________________________________________

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__History of Onset:____________________________________________________________________________________________

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__Client Description of Problem/Concern:__________________________________________________________________

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__Parent and Guardian Description of Problem/Concern:_________________________________________________

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Strengths and Resources Client Description of Strengths:

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Client Description of Support System (i.e. family, friends):

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Client Description of Resources (i.e. entitlement programs, transportation):

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Description of Recreational/Leisure Activities and Frequency of Involvement:

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__Description of Spiritual Involvement:_____________________________________________________________________

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__Other Agencies Involved Currently with Client or Family (List):________________________________________

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__Client Needs and Weaknesses:_____________________________________________________________________________

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Developmental/Family/Social History Current Marital Status:

Single Married Divorced Separated Cohabitating Widowed

__Number of Children (List Ages):___________________________________________________________________________

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__List who lives with the client currently and their relationship to the client:__________________________

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__Type of Housing (i.e. shelter, apartment):_________________________________________________________________

Description of relationship with:

__Parents:______________________________________________________________________________________________________

__Siblings:______________________________________________________________________________________________________

__Children:_____________________________________________________________________________________________________

__Significant Other:____________________________________________________________________________________________

__Extended Family:____________________________________________________________________________________________

__Who did the client grow up with?__________________________________________________________________________

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__Was there any separation from the client’s parent(s) during childhood? If yes, explain:_____________

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__Client’s Health During Pregnancy and/or Birth:__________________________________________________________

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__Client’s History Meeting Developmental Milestones:____________________________________________________

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__Special Services Used as Child/Currently to Assist Client to Meet Developmental Milestones:______

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__Cultural Background and Considerations:________________________________________________________________

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__History or Current Involvement in Military (specify deployments, length of time, combat):_________

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Employment Status (check one):

Full Time Part-Time Per Diem Unemployed

Seasonal Retired Disabled Other:

__Describe any Areas of Employment Concern:_____________________________________________________________

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__Source of Income:___________________________________________________________________________________________

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Education Background (Check/Complete all that apply) Elementary Education:

Positive Peer Relationships Conflicted Peer Relations Conflicted Teacher Relations

Was bully Was bullied

Good student Average Student Poor student

Learning Disabilities Not applicable due to age

School Attended: Highest Grade Completed:

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High School Education:

Positive Peer Relationships Conflicted Peer Relations Conflicted Teacher Relations

Was bully Was bullied

Good student Average Student Poor student

Learning Disabilities Not applicable due to age

School Attended: Highest Grade Completed:

Post High School Education:

Client did not attend Number of years:

Highest degree or certificate received:

Major study or subject area:

Current Legal Concerns (check all that apply)

Probation Bail/Parole OUI

Incarcerated Court Pending Protection Order

Other Legal Concern(s):______________________________________________________________________________________

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Medical & Health History

Current Medical Concerns/Problems:_______________________________________________________________________

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Current Medication Listing:

Medication Dose Frequency Prescriber

History of medical concerns/problems:_____________________________________________________________________

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Do you have a history of, or currently, any communicable diseases (i.e. TB, Hepatitis B or C, MRSA?) __________________________________________________________________________________________________________________

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History of hospitalizations/surgeries_______________________________________________________________________

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Dental Needs:__________________________________________________________________________________________________

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Nutrition Status:_______________________________________________________________________________________________

Client’s Diet Pattern (Meals Per Day)________________________________________________________________________

Weight loss/weight gain:_____________________________________________________________________________________

Describe Changes in Appetite:_______________________________________________________________________________

Describe any disordered eating present:____________________________________________________________________

Describe the client’s sleep patterns:_________________________________________________________________________

__________________________________________________________________________________________________________________

Mental Health History

Client Treatment History: indicate if client has participated in any of the following treatments and if so include provider names, dates, interventions, and client view of outcomes:

Outpatient Therapy:

HCT, 65M, MST:

ACT:

Intensive Outpatient:

Inpatient:

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Family history of mental illness (diagnosis and relationship to client):__________________________________

__________________________________________________________________________________________________________________

Current Risk Assessment

Please indicate history of the following and the date of the last occurrence:

Suicidal Ideation: Suicide Attempt(s):

Homicidal Ideation: Property Destruction:

Aggression: Running Away:

Antisocial Behavior: Problem Gambling:

Other Relevant Information:

Current Risk Assessment

Current Risk: Check all that apply

Suicidality None Ideation Plan Intent w/Plan Intent w/o Plan Details:

Homicidality None Ideation Plan Intent w/Plan Intent w/o Plan Details:

Does the client have access to firearms?

No Yes (List details):

Client’s assessment of risk

Low Moderate High

Clinical assessment of risk

Low Moderate High

*Attach crisis plan if client is at Medium or High risk of crisis; client has history of suicidality or homicidality; self-harm; harm to others; or domestic violence.

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Further comments:____________________________________________________________________________________________

__________________________________________________________________________________________________________________

Abuse Emotional

Victim Witness Offender None

Description of incident(s) including nature of relationship, duration, and severity

Neglect

Physical

Sexual

Other traumatic events (i.e. natural disaster, war or cultural trauma, accidents):_______________________

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Substance Use Substance Use in History

Not reported Tobacco OTC Prescription

Medication

Alcohol

Caffeine Inhalants Stimulants Cocaine Tranquilizers

Marijuana Hallucinogens Methadone Opiates Barbiturates

Methamphetamines Other:

Substance Age of 1^st Use

Current Amount/

Frequency

Duration of Use

Date of Last Use

Period of Heaviest Use

Previous Substance Abuse Treatment(s)

Response to Previous Treatment(s) Detoxification

Rehabilitation Intensive Outpatient Outpatient Therapy Methadone

Suboxone Other

Please describe successful strategies or interventions used in the past that were helpful for the client to maintain periods of sobriety:_______________________________________________________________________

__________________________________________________________________________________________________________________

Has the client experienced any of the following problems related to substance use?

Blackouts Health Issues Legal Issues Relationship Problems

School Problems Other (list):

Family history of substance abuse:__________________________________________________________________________

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Mental Health Status Check all that apply:

Appearance Manner Attention

Appropriate Cooperative Alert

Inappropriate Uncooperative Lethargic/Drowsy

Other: Guarded Confused

Agitated Hypervigilent

Withdrawn Needs Redirection

Other: Inattentive

Selective Other:

Speech Mood Affect

Normal rate Depressed Appropriate

Pressured Angry Inappropriate

Rapid Happy Flat

Slow Worthless Constricted

Slurred High energy Labile

Incoherent Hopeless Congruent with mood

Loud volume Anxious Other:

Soft volume Irritable

Normal volume Elated

Other: Fearful

Other:

Thought Processes

Content Associations Psychological Signs

Appropriate Logical Obsessive

Somatic Relevant Phobic

Persecutory Looseness Compulsive

Paranoid Goal directed Anxious

Ideas of reference Tangential Amnesiac

Bizarre ideations Circumstantial Conversion

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Hallucinations: (type) Other:

Cognitive Level

Intellectual Level Memory Judgment

Above average Intact Intact

Average Impaired Impaired

Below average Poor recent memory

Not determined Poor remote memory

Withdrawn Oriented to

Insight Amnesia Person

Partial Other: Place

Acceptable Time

Absent Disoriented

Client Needs/Weaknesses

__Personal Needs:_____________________________________________________________________________________________

__________________________________________________________________________________________________________________

__Social Needs:_________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Barriers to Treatment

Finances Transport Physical disability Without social supports

Work schedule Family Objections Insurance restrictions

__Other Barriers:______________________________________________________________________________________________

Clinical Summary

(Should include: Significant historical information, clinical interpretation/diagnosis, treatment needs, choice of treatment modality, frequency and duration of sessions; and expected length of time in treatment)

_____________________________________________See

attached_______________________________________________________

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Intake Diagnosis / DSM IV

All need to be filled in and who diagnosed Axis I Code(s) & Description(s):

___304.00 Opiate Dependence________________________________________________________________________________

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Axis II Code(s) & Description(s):

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Axis III (Physical Disorders) Description & Source of Information:

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Axis IV (Psychosocial Stressors) Description(s):

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Axis V (GAF) ______________________________

Follow-Up / Referral Recommendations

__Psychological Evaluation: _None___________________________________________________________________________

__Psychiatric or Medication Evaluation:__None_____________________________________________________________

__Medical/Primary

Care:__None______________________________________________________________________________

Treatment Recommendations

Individual Therapy Crisis Intervention

Family Therapy X Intensive Outpatient

X Group Therapy (specify):

1. Will be decided at discharge from IOP

Other (Specify):

Signatures

Client (optional): Date:

Parent/Guardian (optional): Not applicable Date: None

Clinician: Date: