Initial Intake Assessment
Why are you searching for assist at the moment?
What are you struggling with the maximum?
Motivation and Support:
How does your circle of relatives experience about the possibility of you coming to our Center?
Why do you need intensive assist now as opposed to 30 days in the past or one month from now?
If a hundred% means 100% dedicated, how dedicated are you to giving up your ingesting disorder and getting nicely? (Please supply your reaction in a percentage.)
Previous Treatment History:
Start at the start along with your first treatment and listing dates, facilities, and experts from whom you’ve got acquired remedy. (dates inpatient/outpatient; MD/therapists’ names and get in touch with numbers)
How have you felt approximately the treatment you have got received?
Has it helped you? If yes, in what approaches?
If it has not helped in the beyond, why not?
Non-psychiatric, fashionable medicinal drugs you’re presently taking:
History from beginning to the existing for psychiatric medicines:
Are there any medications that have helped you extensively inside the beyond?
Are any immediate circle of relatives contributors on psychiatric medicines? Which family member and which medicinal drug(s)?
Are the medications you’re presently taking assisting you?
If you are not presently on medicine(s), are you willing to recall taking psychiatric remedy?
(Answer the following questions with regard to your family of foundation and prolonged own family.)
Are you married, single, or divorced?
How many kids are on your family of foundation?
What is your delivery order in your family of foundation?
How is your parents’ marriage?
Any family records of emotional, physical, or sexual abuse?
Any family records of criminal hobby?
Any family records of bipolar or psychotic illness?
Any family records of inpatient psychiatric hospitalizations?
Any family records of alcohol or substance abuse?
Describe your relationship with your mom:
Describe your relationship along with your father:
Describe your relationship together with your spouse if married:
Do you’ve got any cutting-edge medical problems or conditions?
Have you been in any serious accidents? If yes, please provide an explanation for.
Have you been hospitalized for any reason? If yes, please give an explanation for.
Patient History and Current Situation:
Have you skilled any extreme losses to your life? What, who, when?
Have you ever experienced any disturbing occasion in your lifestyles?
Are you beneath huge stress right now?
What are the present day stressors to your life?
Have you ever skilled, these days or in childhood, any sexual, bodily, emotional, or verbal abuse? If sure, please describe:
Eating Disorder History:
When did you first be aware feeling depressed?
Describe the records of your despair:
When did you first begin having consuming ailment issues?
How did your consuming disorder first start?
Tell me how your consuming ailment developed through the years:
What is your cutting-edge height and weight?
What is the most you have got ever weighed and whilst?
What is the least you have ever weighed and whilst?
Have you ever abused/used over-the-counter weight-reduction plan pills, avenue meth, laxatives, or diuretics? If so, whilst and what?
Do you binge and purge? How tons meals and how regularly?
What is your envisioned each day caloric intake at the moment?
Describe your exercising habits:
How do you experience about your frame?
What is the amount of weight you’ve got won or lost within the final 60 days?
Have you ever been arrested? If so, please provide an explanation for.
Have you ever shoplifted? If so, please give an explanation for.
Have you ever been arrested for DUI?
Have you ever abused every body in any manner?
Have you ever been diagnosed with an intellectual handicap, a studying incapacity, or ADHD?
Have you ever been in Resource or unique education packages at school?
How did you do in school with class content material, kids, and instructors?
Are there any regions of warfare or wonderful achievement in college?
Current Educational Pursuits/Work Record and Current Job Situation:
What is your cutting-edge GPA?
What became your high faculty GPA?
Special pastimes in school or principal:
Do you currently have a process? If so, where do you work and what do you do?
What are your educational and vocational dreams within the future?
Do you stay with instantaneous circle of relatives? (yes or no)
Geographically, how near is your closest immediate member of the family?
How frequently do you go to with circle of relatives by way of smartphone or in man or woman?
When you’re with them, how is it?
Do you have got a process?
Have you recently misplaced a process?
Are you able to characteristic at paintings?
Are you currently attending college?
How are you doing on your lessons?
Are you lacking classes or losing in performance academically? Please explain:
Are you capable of care for yourself?
Are you capable of care for your youngsters?
Are you socially energetic or isolative? Please describe:
POTENTIAL OF SUICIDE/SELF-INJURY none, slight, mild, extreme, current suicide ideation, intent, past range of tries: cutting-edge suicide plan: Self-Injury/mutilation-modern-day, past (describe):
POTENTIAL FOR VIOLENCE none, moderate, mild, intense, verbally aggressive, physically aggressive. Please describe:
IMPAIRED REALITY TESTING/DISSOCIATIVE EPISODES List deficits: reminiscence, delusions, judgment, evasive, confusion, suspicious, auditory hallucinations, visible hallucinations, perceptual disturbance
ALTERATION IN MOOD/AFFECT incongruent, tearful, lack of attention, worthlessness, hopeless, guilt emotions, labile, angry, withdrawn, despondent, euphoric, lack of hobby, problems making selections, lack of motivation, affect: different:
MOOD SWINGS Describe:
DYSFUNCTIONAL SLEEPING PATTERNS none, early morning awakenings, common awakenings, immoderate sleep, issue falling asleep, sleepless nights
DYSFUNCTIONAL EATING PATTERNS none, bulimia (describe), anorexia (describe), appetite adjustments, current weight loss/advantage, obsessive mind or compulsive patterns/rituals (describe)
ANXIETY none, slight, excessive, panic, signs, fears or phobias
SUBSTANCE ABUSE none, alcohol (quantity, frequency, final drink), capsules (type and frequency), prescription/OTC:
HISTORY OF ABUSE none, sexual, bodily, emotional, describe:
Diagnostic Impressions (preliminary):
DSMIV, Axis I, II, III, IV, V, Medical Concerns, Current Stressors, Current GAF, Highest GAF beyond year:
Treatment Recommendations and Needs:
Outpatient, inpatient, day software
Possible remedy needs:
Possible scientific consult wishes:
Possible testing/assessment desires:
Additional Comments or Concerns:
by Michael E. Berrett, PhD