Psych Clinic Intake & Report Outline
Psych Clinic Intake & Report Outline
Psych Clinic Intake & Report Outline
NAME:
ID NUMBER:
ADDRESS:
INTAKE DATE:
DATE OF BIRTH:
PHONE:
HOME:
WORK:
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(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.) and
severity of stressors (see DSM IV, Axis IV).
(c) Note the clients highest level or adaptive functioning the past year (12 Mon.
See DSM IV, Axis V).
(d) Previous conditions, psychiatric hospitalizations and/or treatment which were
similar to or the same as the presenting complaint (this information is often
asked on insurance claim forms).
MEDICAL:
PERSONAL HISTORY:
This should briefly include any relevant occurrence (developed chronologically) and
can use the following headings as a guide:
(a) Birth and Infancy: Were there any difficulties or special circumstances
(medical, adoption, frequent moves, etc.)
(b) Childhood: Overall adjustment and relationships to peers as well as academic
performance (e.g., did above-average work in school and reported positive peer
relationships).
(c) Adolescence: Further development including any behavioral changes, family
circumstances, peer adjustment, education, and relationships with the opposite
sex.
(d) History up to time of presenting complaint including vocational information,
dating/sexual experiences, and marital relationship(s) if applicable. Note
present living arrangement and significant socio-economic circumstances or
influences.
FAMILY CONSTELLATION:
List significant persons in clients environment, their geographic location, and
quality of relationship (e.g., Mr. B., brother, age 33, lives in Albuquerque, single,
and unemployed relationship with Mrs. X. is described as conflictual as he has a
long history of alcohol abuse and wont help me much less himself).
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TENTATIVE DIAGNOSIS:
(1) According to DSM IV, or (2) Dynamic formulation with clinical features, or (3)
Reason for contact with the agency. (DSM IV V codes may be utilized.)
INITIAL TREATMENT RECOMMENDATIONS:
(a) State type of treatment utilized (e.g., crisis, insight-oriented, supportive,
behavioral, psychotherapy, etc.), the treatment modality (e.g., estimated
length of treatment, changes in modality, etc.). Include designation of
the primary therapist(s) (e.g., Will be seen by the undersigned and Ms. Z,
MSW in group therapy).
(b) Treatment focus and/or goals with specific reference to the clients
reason for seeking treatment.
(e.g., Initial treatment recommendation is individual psychotherapy on a once weekly
basis. Therapy will focus on Mrs. S.s presenting concerns around her relationship
with boyfriend and child management issues. Couple treatment is possible in the
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future, but boyfriend presently refuses to attend sessions. Will work on symptom relief
(early morning wakening) and increasing her ability for pleasurable experiences, etc.).
FINANCIAL INFORMATION:
Brief description of financial status (monthly income and financial obligations), (if
relevant), means of payment (weekly or any use of insurance).