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    Initial Intake Assessment

    Presenting Problem:

    Why are you seeking help at this time?

    What are you struggling with the most?

    Motivation and Support:

    How does your family feel about the possibility of you coming to our Center?

    Why do you want intensive help now as opposed to 30 days ago or one month from now?

    If 100% means 100% committed, how committed are you to giving up your eating disorder and getting well? (Please give your response in a percentage.)

    Previous Treatment History:

    Start at the beginning with your first treatment and list dates, facilities, and professionals from whom you have received treatment. (dates inpatient/outpatient; MD/therapists’ names and phone numbers)

    How have you felt about the treatment you have received?

    Has it helped you? If yes, in what ways?

    If it has not helped in the past, why not?

    Medications:

    Non-psychiatric, general medications you are currently taking:

    History from beginning to the present for psychiatric medications:

    Are there any medications which have helped you significantly in the past?

    Are any immediate family members on psychiatric medications? Which family member and which medication(s)?

    Are the medications you are currently taking helping you?

    If you are not currently on medication(s), are you willing to consider taking psychiatric medication?

    Family History:

    (Answer the following questions with regard to your family of origin and extended family.)

    Are you married, single, or divorced?

    How many children are in your family of origin?

    What is your birth order in your family of origin?

    How is your parents’ marriage?

    Any family history of emotional, physical, or sexual abuse?

    Any family history of criminal activity?

    Any family history of bipolar or psychotic illness?

    Any family history of inpatient psychiatric hospitalizations?

    Any family history of alcohol or substance abuse?

    Describe your relationship with your mother:

    Describe your relationship with your father:

    Describe your relationship with your spouse if married:

    Medical History:

    Do you have any current medical problems or conditions?

    Have you been in any serious accidents? If yes, please explain.

    Have you been hospitalized for any reason? If yes, please explain.

    Patient History and Current Situation:

    Have you experienced any serious losses in your life? What, who, when?

    Have you ever experienced any traumatic event in your life?

    Are you under significant stress at this time?

    What are the current stressors in your life?

    Have you ever experienced, recently or in childhood, any sexual, physical, emotional, or verbal abuse? If yes, please describe:

    Eating Disorder History:

    When did you first notice feeling depressed?

    Describe the history of your depression:

    When did you first begin having eating disorder problems?

    How did your eating disorder first start?

    Tell me how your eating disorder developed over time:

    What is your current height and weight?

    What is the most you have ever weighed and when?

    What is the least you have ever weighed and when?

    Have you ever abused/used over-the-counter diet pills, street meth, laxatives, or diuretics? If so, when and what?

    Do you binge and purge? How much food and how often?

    What is your estimated daily caloric intake at this time?

    Describe your exercise habits:

    How do you feel about your body?

    What is the amount of weight you have gained or lost in the last 60 days?

    Legal Problems:

    Have you ever been arrested? If so, please explain.

    Have you ever shoplifted? If so, please explain.

    Have you ever been arrested for DUI?

    Have you ever abused anyone in any way?

    Educational Background/Concerns:

    Have you ever been diagnosed with an intellectual handicap, a learning disability, or ADHD?

    Have you ever been in Resource or special education programs at school?

    How did you do in school with class content, kids, and teachers?

    Are there any areas of struggle or exceptional achievement in school?

    Current Educational Pursuits/Work Record and Current Job Situation:

    What is your current GPA?

    What was your high school GPA?

    Special interests in school or major:

    Do you currently have a job? If so, where do you work and what do you do?

    What are your educational and vocational goals in the future?

    Family Involvement:

    Do you live with immediate family? (yes or no)

    Geographically, how close is your closest immediate family member?

    How often do you visit with family by phone or in person?

    When you are with them, how is it?

    Mental Status:

    Functioning Level:

    Do you have a job?

    Have you recently lost a job?

    Are you able to function at work?

    Are you currently attending school?

    How are you doing in your classes?

    Are you missing classes or dropping in performance academically? Please explain:

    Are you able to care for yourself?

    Are you able to care for your children?

    Are you socially active or isolative? Please describe:

    Psychiatric Symptoms:

    POTENTIAL OF SUICIDE/SELF-INJURY none, mild, moderate, severe, current suicide ideation, intent, past number of attempts: current suicide plan: Self-Injury/mutilation-current, past (describe):

    POTENTIAL FOR VIOLENCE none, mild, moderate, severe, verbally aggressive, physically aggressive. Please describe:

    IMPAIRED REALITY TESTING/DISSOCIATIVE EPISODES List deficits: memory, delusions, judgment, evasive, confusion, suspicious, auditory hallucinations, visual hallucinations, perceptual disturbance

    ALTERATION IN MOOD/AFFECT incongruent, tearful, lack of concentration, worthlessness, hopeless, guilt feelings, labile, angry, withdrawn, despondent, euphoric, lack of interest, problems making decisions, lack of motivation, affect: other:

    MOOD SWINGS Describe:

    DYSFUNCTIONAL SLEEPING PATTERNS none, early morning awakenings, frequent awakenings, excessive sleep, difficulty falling asleep, sleepless nights

    DYSFUNCTIONAL EATING PATTERNS none, bulimia (describe), anorexia (describe), appetite changes, recent weight loss/gain, obsessive thoughts or compulsive patterns/rituals (describe)

    ANXIETY none, moderate, severe, panic, symptoms, fears or phobias

    SUBSTANCE ABUSE none, alcohol (quantity, frequency, last drink), drugs (type and frequency), prescription/OTC:

    HISTORY OF ABUSE none, sexual, physical, emotional, describe:

    Diagnostic Impressions (preliminary):

    DSMIV, Axis I, II, III, IV, V, Medical Concerns, Current Stressors, Current GAF, Highest GAF past year:

    Treatment Recommendations and Needs:

    Outpatient, inpatient, day program

    Nutritional Outpatient

    Possible medication needs:

    Possible medical consult needs:

    Possible testing/assessment needs:

    Additional Comments or Concerns:

    by Michael E. Berrett, PhD



    Source by Michael E. Berrett, Ph.D.

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