Clinical & Wellness Service

Intake –Family

CROSS COUNSELING & BEHAVIORAL HEALTH, LLC

Intake – Family

- CONFIDENTIAL -

Today’s Date: ______

Primary Client’sName: ______

Date of Birth: ______/______/______Age: ______SSN: ______-______-______

Primary Home Address: ______

______

City StateZip

(Dwelling Type: ______)

Home phone: ______Alternate phone: ______

Participating Family Members

Names of family members who will be participating in family therapy:

Name: ______DOB: ______Age: ______

Reason for Referral

Please state the current and/or previous concerns regarding the family.

What significant stressful events has your family experienced recently?

What specific problems or concerns would you like us to help with at this time?

What would you like to accomplish out of your time in family therapy?

Family Medical and Mental Health History

Have any biological family members presented symptoms or have been diagnosed with the following:

CONDITION/DISEASE / FAMILY MEMBER(S) / COMMENTS
Allergies
Anemia
Breathing Problems
Blood Disorder
Cerebral Palsy
Mumps
Chicken Pox
Cancer/ Leukemia
Measles
Pneumonia
Diabetes
Meningitis
Broken Bones
Heart or Lung Disease
Kidney Disease
Tuberculosis
Frequent Ear Infections
Seizures/Epilepsy
Sexually Transmitted Disease
Thyroid Problems
Lead Poisoning
Stroke
Hypertension/ High Blood Pressure
Sleep Problems (Sleep Apnea, Narcolepsy)
Multiple Sclerosis
Hypoglycemia
Dementia
Drug Exposure
Substance Abuse
Learning Disability
Tourette’s/ Tics
Schizophrenia
Anxiety/ Nervousness
Depression
Suicidal Behavior
Homicidal Behavior
Other:

Is there history of substance abuse including use of tobacco, alcohol, or illegal drugs, including misuse of prescription drugs? Describe drug usage, including substance(s) of choice, duration, and extent.

_____Alcohol _____Marijuana_____Caffeine_____ Tobacco

_____Cocaine_____Hallucinogens_____Methadone_____ Methamphetamines

_____Barbiturates_____Opiates_____Tranquilizers_____ Pain Medications

_____Inhalants_____Stimulants_____Sedatives_____ OTC Medications

_____Other: ______

Substance / Amount/ Frequency

To your knowledge, has there been physical, emotional, or sexual abuse or neglect? If yes, please discuss details of the circumstances and any interventions from legal and/or other child protection entities.

Has there been a history or current experience of inpatient psychiatric treatment or outpatient counseling? Please discuss when, duration, and circumstances of treatment.

Has there been any history or current experience of suicidal/homicidal ideation and/or attempts? Emergency room visits? Other interventions?

Household

Household Composition (Who lives in the home?)

Name AgeOccupationRelationship

______

Other Immediate/Relevant Family Members

Name AgeOccupationRelationship

______

Please discuss the relationship history of primary caregivers in the household, including marital status, any separations/divorce, and custody/visitation schedules.

Have there been any major family stresses or changes in the past year (i.e., moves, divorce, significant illness, etc.)? If yes, please describe the circumstances and familyreactions.

Has the family experienced any major losses (either by death or separation)? If yes, please explain.

Who is financially responsible for the household? Who contributes to the running of the household (i.e., financially, childcare, etc.)? How?

Is the family involved in any organized activities (i.e., sports, social organizations, religious/ spiritual)?

What do you consider to be some of your family weaknesses?

What do you consider to be some of your family strengths?

Is there anything else you would like for me to know at this time?

Mental Status Exam Checklist

(Detail for the primary client; however, make note of all family members)

Appearance / {Gender M F } Neat, Appropriate, Inappropriate, Underweight, Overweight, Obese, Appeared stated age, Appeared older than stated age, Appeared younger than stated age, Sloppy, Soiled, Flamboyant, Sexually provocative, Frail, Muscular, Adequate eye contact, Poor eye contact, Expressionless, Physical Deformation:______
Behavior / Cooperative, Relaxed, Dramatic, Preoccupied, Guarded, Suspicious, Evasive, Hostile, Disruptive, Bizarre, Charming, Hypersexual, Flirtatious, Aloof, Fidgety, Fearful, Callous, Tearful, Distant, Negative, Friendly, Shy
Orientation / Oriented x [Person, Place, Time, Situation], Conscious, Unconscious, Drowsy, Amnesia, Clouding of Consciousness
Motor Activity / Purposeful, Retarded, Hyperactive, Rigid, Fidgety, Catatonic, Tics, Rapid blinking, Hand ringing/shaking, Shaking legs, Rocking, Awkward, Staggering, Shuffling, Rigid, Trembling
Speech / Normal, Accent
Clear and coherent, Soft, Loud, Pressured, Slow, Mumbled, Whispering, Slurred, Stuttering, Monotonic, Echolalia, Mute
Mood / Euthymic, Dysphoric, Euphoric, Angry, Anxious, Apathetic, Sullen, Calm, Irritated
Affect / Congruent, Incongruent, Flat, Inappropriate, Labile, Restricted, Superficial
Thought Form/Process / Goal-directed, Reality-focused, Flight of ideas, Loose association, Perseveration, Indecisive, Circumstantial, Tangential, Disorganized, Blocking, Coherent
Thought Content / Persecution, Reference, Somatic, Grandiose, Influence, Phobias, Depersonalization, Superstitions, Obsessive/Rituals, Compulsions, Hopeless, Helpless, Worthless, Antisocial attitudes, Hyper-religious, Sexual preoccupation, Violent, Guilt, Blames others, Suicidal, Impulsive, Poverty of content
Hallucinations / None, Auditory, Visual, Tactile, Olfactory, Gustatory
# of voices/visions/contact ______, Friendly, Stranger, Aggressive, Muffled, Clear, Command:______
Delusions / None, Control, Reference, Persecution, Sexual, Grandiose, Religious, Somatic, Paranoid, Bizarre, Jealous
Insight / Good, Fair, Poor, Marginal
Motivated for change, Unmotivated for change, Does not know the reason for referral
Judgment / Good , Fair, Poor, Displays impulse control, Lack of impulse control, Displays frustration tolerance/delayed gratification, Impaired frustration tolerance/delayed gratification, Accepts responsibility, Impaired sense of responsibility, Blames others, Naïve
Intellectual Functioning / Below Average, Average, Above Average
Stressors / Money, Housing, Family conflict, Work, Grief/losses, Illness, Transitions, Shift changes, Safety concerns, Danger on the job, Abuse history
Support / Family, Friends, Church, Service systems, Peer counseling, Counselor, Therapist, Case Manager, Psychologist, Psychiatrist