1

Rebecca E. Bombet, MS, APRN, BC

Child, Adolescent and Family Therapist

Initial Evaluation

Client Name: ______Intake Date: ______
DOB:______Age: ______Sex:______Religion:______
Allergies:______
Information given by:______
Presenting Problem:
History of Presenting Problem:
Psychiatric Treatment History:
Outpatient History
·  Therapist ______
·  Duration ______
·  Outcome ______
Inpatient History
·  When/where______
·  Physician______
·  Outcome______
Medication
Medication / Reason / Dosage / Taken as Prescribed / Physician

Psychosocial History

Developmental History

·  Duration of Pregnancy: ______

·  Smoking during pregnancy: __Yes __No ______

·  Alcohol during pregnancy: __Yes __No ______

·  Drugs during pregnancy: __Yes __No ______

·  Medications during pregnancy: __Yes __No ______

·  Complications: ______

Delivery

·  Labor & Delivery: __ Spontaneous ___ Induced __Normal __Cesarean __Breech

·  Duration (hours)______

·  Premature __Yes __No # of weeks______

·  Birth Weight ______Infant Days in Hospital______

·  Complications______

Milestones

·  Breast fed: _____Yes _____No Problems:______

·  Motor Skills: Age at walking ______Age at talking:______Problems:______

·  Social Attachment: ______

______

Problems during infancy/early childhood : ______

___Bedwetting _____ Night Terrors Other:______

Medical

·  Childhood illnesses/disorders (include dates and ages):______

______

·  Operations (include dates and ages): ______

______

·  Hospitalizations(include dates and ages):______

·  Head Injuries ____without loss of consciousness ____with loss of consciousness Duration______Details______

·  Convulsions ____without fever _____with fever

Details:______

Allergies:______

______

Glasses/Contacts: _____Yes _____No

Braces/Retainer: _____Yes _____No

Other Medical Problems:______

______

Substance Abuse History:

Alcohol / Type / Frequency / How Long / Last Use
Drugs / Type / Frequency / How Long / Last Use

·  Client Attitude toward AA/NA:

·  Family Attitude towards use:

Suicidal/Homicidal Ideations:

·  Is client suicidal? ______

Does client have a plan? Yes ____ No ____

When:

Where:

Method:

Previous suicide attempts: (give details)______

______

·  Is client homicidal?______

Does client have a plan? Yes ____ No ____

When:

Where:

Method:

Previous homicide attempts: (give details)______

______

Abuse History:

·  Physical Abuse ______

·  Sexual Abuse ______

·  Emotional Abuse ______

·  Mental Abuse ______

·  Abandonment/Neglect ______

·  Other ______

Details if answered yes to above

·  Length/Duration______

·  Ages(s)______

·  Reported to Authorities(DEFAC): ______Yes _____No

·  Details______

______

·  Witness(s) of Abuse: ____ Yes _____ No ______

·  Perpetrator of Abuse? __Yes __No ______

Family and Social History

·  Family Constellation

Mother______Age_____ Educational Level______

Occupation______

Father______Age____Educational Level______

Occupation______

Parents are __married __separated __divorced Year______

·  Siblings ( Half/Step): ______

______

·  Describe family relationships (past and current): ______

______

Custody Issues: _____ Yes _____ No If so, describe:______

______

______

Family History of;

·  Substance Abuse______

______

·  Mental Illness______

______

·  Suicide______

·  Violence______

·  Other______

Social History

·  Peer relations______

______

·  Gang Involvement______

·  ______Relations with Authority______

______

·  Social support networks______

______

·  Hobbies/Interests______

______

Educational

·  Education Level______

·  Age started 1st grade______

·  Attended __infant day care __pre-school __kindergarten

·  Official School Classifications (details below)

__LD or ADHD __ED __MR __Visually impaired ___Hearing impaired

Other:______

·  Type of Placement (details below)

__regular classes __special education __honors (T&G) __home study

Details:______

·  Adjustment Issues: ______

______

·  Behavioral problems:______

______

·  Repeated grades:______

·  Suspensions/Expulsions: ______

______

·  Performance/Achievements:______

______

·  Attitude toward school:______

Strengths/Weaknesses

·  Strengths:______

______

·  Weaknesses:______

______

______

Occupation

·  Current Employment

__Employed FT __Employed PT __Unemployed __Student

Describe:______

Sexual Behavior and Orientation

·  Orientation

__heterosexual __homosexual __bi-sexual __unsure

·  Sexual history______

·  Tested for STD’s:

_____ Chlamydia ______AIDS ______GC ______Syphilis

Results:______

Legal History

·  Pending charges______

______

·  Arrests______

·  Convictions______

·  Jail/ Prison______

·  Parole Officer______

Phone Number______

·  Probation : ______

·  Juvenile Detention______

·  DJS Involvement______

DJS Worker______Phone Number______

MENTAL STATUS EXAM

Appearance: Manner of Relations/Observed Behaviors

[ ] Age appropriate [ ] Reliable informant [ ] Withdraw lethargic

[ ] Younger than age [ ] Unreliable informant [ ] Hypoactive

[ ] Older than age [ ] Mute [ ] Hyperactive

[ ] Bizarre [ ] Cooperative [ ] Bizarre

[ ] Seductive [ ] Uncooperative [ ] Needs reassurance

[ ] Attention seeking [ ] Provocative [ ] Suspicious

[ ] Flamboyant [ ] Hostile [ ] Hypervigilant

[ ] Overweight [ ] Threatening [ ] Controlling

[ ] Underweight [ ] Appropriate [ ] Argumentative

[ ] Neatly groomed [ ] Inappropriate [ ] Resistant antagonistic

[ ] Disheveled [ ] Calm [ ] Manipulative

[ ] Unclean [ ] Restless [ ] Passive submissive

[ ] Appears ill [ ] Agitated [ ] Passive Aggressive

[ ] Appears intoxicated [ ] Tearful [ ] Aggressive

[ ] Appears in withdrawal [ ] Sighing [ ] Dependent

[ ] Appears in control [ ] Slurred speech [ ] Loud speech

[ ] Appears out of control [ ] Intoxicated [ ] Soft speech

[ ] Unusual describe [ ] Disinterested [ ] Rapid speech

[ ] Pressure speech

[ ] Slow speech

[ ] Negativistic

[ ] Guarded eves

Intellectual Level: [ ] above average [ ] average [ ] below average

Mood:

[ ] Affect [ ] Fear [ ] Dysphoric

[ ] Appropriate [ ] Vacuous [ ] Sadness/grief

[ ] Inappropriate [ ] Guilty [ ] Fatigue

[ ] Stable [ ] Ashamed [ ] Withdrawal

[ ] Range [ ] Remorseful [ ] Mildly depressed-dissatisfied

[ ] Blunted [ ] Anxious [ ] Unexplained crying

[ ] Flat restricted broad [ ] Panicky [ ] Moderately depressed

[ ] Euphoric [ ] Worthless [ ] Very depressed

[ ] Happy [ ] anhedonic [ ] Self reproach

[ ] Irritable [ ] Mood swings [ ] Self-centered

[ ] Angry [ ] Ambivalent [ ] Suicidal

[ ] Relieved [ ] Elated [ ] pathetic

[ ] Sad [ ] Labile [ ] Guilt

[ ] Depressed [ ] Flat [ ] Silly

[ ] Dysphoric [ ] Anxious [ ] Fear

Motor Behavior:

[ ] Normal [ ] Usual [ ] Gait

[ ] Agitation [ ] Hand ringing [ ] Impulsiveness

[ ] Akathisia [ ] Pill rolling [ ] Hyperkinesia

[ ] Choreiform movements [ ] Posture abnormal [ ] Hyperactive

[ ] Compulsive behavior [ ] Shuffling [ ] Hypoactive

[ ] Cataplexy [ ] Poor balance

[ ] Catatonic excitement [ ] Pressured behavior

[ ] Catatonic stupor [ ] Few actions

[ ] Dyskinesia [ ] Slow

[ ] Dystonic [ ] Waxy flexible

[ ] Tremors [ ] Psychomotor retardation

[ ] Echopraxia [ ] Parkinson-like Sx

Rate of Speech :

[ ] Slowed [ ] Pace [ ] Pauses

[ ] Latency [ ] Delay before begin

[ ] Halting [ ] Occasional/arbitrary delay

[ ] Blocking [ ] Like continuation, But doesn’t continue on topic

[ ] Spontaneous [ ] Monotone

[ ] Animated [ ] Variation in tone, pitch [ ] Very expressive

[ ] Volume & intonation [ ] Stutter [ ] Lisp

[ ] Loud [ ] Word-finding difficulty [ ] Soft

[ ] Slurred [ ] Impediment

Unusual Speech:

[ ] Aphasia [ ] Verbigeration [ ] Clanging [ ] Echolalia [ ] Mutism [ ] Preservation [ ] Neologisms

Insight and Judgment : Sensorium and Cognitive Functions

Intact Impaired

[ ] Intact judgment [ ] [ ] Orientation to person

[ ] Impaired judgment [ ] [ ] Orientation to place

[ ] Realizes need for help [ ] [ ] Orientation to time

[ ] Ambivalent about help [ ] [ ] Orientation to situation

[ ] Denial [ ] [ ] Recent memory

[ ] Blames others [ ] [ ] Remote memory

[ ] Minimizes extent of problems [ ] [ ] Immediate recall

REALITY TESTING

Thought Processes: Thought Content:

[ ] Normal concrete scattered illogical [ ] Delusions

[ ] Tangential [ ] Bizarre thoughts

[ ] Loose associations [ ] Suspicious

[ ] Confusion [ ] Paranoid

[ ] Racing thoughts [ ] Grandiose

[ ] Slowed thoughts [ ] Somatic delusions

[ ] Distractible [ ] Ruminations

[ ] Confabulations [ ] Obsessive

[ ] Blocking [ ] Negativism

[ ] Circumstantial [ ] Helpless

[ ] Confabulation [ ] Worthless

[ ] Derailment [ ] Hopeless

[ ] Flight of ideas [ ] Poor self-esteem

[ ] Fragmentation [ ] Suicidal ideation suicidal

[ ] Ideas of reference [ ] Feelings of inadequacy

[ ] Mild loosening [ ] Phobias

[ ] Non-sequitur [ ] Somatizing

[ ] Loose association [ ] Hypochondrias

[ ] Magical [ ] Poverty of thought

[ ] Reference [ ] Relevance

[ ] Persecutory [ ] Word salad

[ ] Stereotypic [ ] Tangential

[ ] Vagueness

MANNER OF RELATING

[ ] Cooperative [ ] Negativistic [ ] Manipulative [ ] Guarded [ ] Disinterested [ ] Withdrawn

[ ] Passive [ ] Submissive [ ] Hostile [ ] Threatening [ ] Antagonistic

[ ] Resistant [ ] Evasive

DRESS / GROOMING / HYGIENE

[ ] Neat [ ] Appropriate [ ] Disheveled [ ] Unusual Comment:______

AFFECT

Range; [ ] Broad [ ] Restricted [ ] Blunted [ ] Flat

Appropriateness; [ ] Appropriate [ ] Inappropriate

Relatedness/ Stability ; [ ] Stable [ ] Labile [ ] Intensity

Provisional Diagnoses (DSM-IV –R)

Axis I: ______

Rule Out: ______

Axis II: ______

Axis III: ______

Axis IV: ______

1 – None 2 – Mild 3 – Moderate 4 – Severe 5 – Extreme

Primary Support Group: ______

Problems related to social environment: ______

Educational Problems: ______

Occupational Problems: ______

Housing Problems: ______

Economic Problems: ______

Problems accessing health care: ______

Problems with Legal System: ______

Other psychosocial problems: ______

______

Axis V:

90 – Absent or minimal symptoms, good functioning in all areas

80 – Transient & expectable reactions to psychosocial stressors

70 - Mild symptoms, but generally functions well

60 – Moderate symptoms

50 – Serious symptoms

40 – Some impairment in reality testing or major impairment in several areas (work, school)

30 – Influenced by delusions or hallucinations or serious impairment in communication or judgment

20 – Some danger of hurting self or others

10 – Persistent danger of severely hurting self or others

0 – Inadequate information

Current GAF: ______Highest GAF in past year: ______

Referral: Admit to ______Psychiatrist ______

Medical Doctor ______Support Group ______AA/NA ______

Initial Therapy Goals:

Goal 1: To evaluate the child/teen and family system.

Goal 2: To assure the safety of the client and monitor mood and behavior.

Goal 3: To develop a trusting relationship with client in order encourage self- disclosure

______

Clinician Signature Date