Adolescent Intake Form Paper

Adolescent Intake Form Paper

ADOLESCENT/CLIENT’S INFORMATION

NAME:
AGE:
GENDER	Male    Female
RACE/ETHNICITY	Caucasian/White     Hispanic     Native American African American/Black     Asian     Biracial                            Other
who referred THE CLIENT?	Self    Parent/Family Member   Teacher   Friend   Other: _____________
What problems/ISSUES DOES THE CLIENT PRESENT WITH?
WHEN DID THESE CONCERNS BEGIN?
Is Treatment Court Ordered?	Yes No   If yes, why:_____________
Employment information:	Full-time Student  Part-time Student   Employed      N/A   Name of Employer:  ____   Job Title:______
LEGAL HISTORY:	Has the child been charged with a crime?    Yes     No Is the child on probation?    Yes     No If yes, please explain: Adolescent Intake Form Paper.
SUBSTANCE USE HISTORY:	NONE    Alcohol    Other substance use: ________________ Attended alcohol/drug abuse treatment: Yes No Has the child been told that they have an alcohol/drug problem:  Yes No

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SCHOOL FUNCTIONING

High School Grade
Past / Present truancy issues	Yes    No
Expulsions	Yes    No     If yes, explain number and reason(s): __________
Suspensions	Yes    No
Repeat Grades	Yes     No
Any special accommodations made for student?	No   504 Plan     Special Education / IEP If yes, explain:

 

SOCIAL, PLAY AND RECREATION

Describe the child’s recreational interests (if any).
Briefly describe significant relationships (many/few friends, best friend, romantic relationships, etc.)

 

Caregiver/HOUSEHOLD information:

Who is primary caregiver of the adolescent?   Parent     Other Relative     Guardian    OTHER If other, explain: Adolescent Intake Form Paper.
Number of household members: Who lives in the home with the child (parent(s), siblings, others, etc.):
Who lives in the home with the child (parent(s), siblings, others, etc.
Brief description of living arrangements
Are there any custody/visitation arrangements?  Please describe.
Describe the child’s family, cultural and religious connections.

 

Mental Health History:

No previous therapy  (Skip to next section of form)

Outpatient Treatment Type of treatment: (Circle all that apply)   Individual therapy   family therapy   group therapy Dates of treatment: _____________________________________ Reason for treatment: __________________________________ Type of treatment: (Circle all that apply)  Individual therapy   family therapy   group therapy Dates of treatment: _____________________________________ Reason for treatment: __________________________________

Inpatient Treatment/Psychiatric Hospitalization Previously hospitalized:  Yes   No   N/A   Multiple Hospitalizations:  Yes ___________   Dates of treatment: _____________________________________ Reason for treatment: __________________________________

Has the child experienced grief and or loss, or significant trauma?   Yes   No  Explain: ___________

 

MEDICAL INFORMATION:

Does adolescent have a primary care physician?	Yes     No Visit/Checkup with PCP within the past 12 months:   Yes   No Regular preventative health screens:  Yes   No
Currently Prescribed Medications	No    Yes   If Yes, identify medications: ______________ Has client been consistently taking medications as prescribed?   No    Yes

 

General Functioning:  (Please check all that apply)

Cheerful/happy mood most of the time                    Extreme ups and downs in mood                Conflict with authority figures

Sad or tearful most of the time                                   Irritability/anger                                             Stealing

Feelings of hopelessness                                              Distinct periods of nonstop activity            Physical cruelty to animals

Withdrawn behaviors                                                    Exaggerated view of abilities                       Physical aggression

Difficulty thinking                                                           Fast/rapid speech                                          Verbal threats to harm others

Under active/sluggish behavior                                   Feels rested after 3-4 hours sleep/ night   Threat to kill with intent /plan

Intentional self harm                                                     Fearless/engaging in reckless activities      Lying

Suicidal thoughts                                                            Fearful of places, situations or people       Extreme conflict with siblings

Suicide attempts                                                             Worries about ____________________   Running away

Increased appetite                                                         Decreased appetite                                        Poor social skills

Nightmares                                                                      Inability to complete tasks                            Inability to sustain attention

Takes more than an hour to fall asleep                     Sexual promiscuity                                        Overactive/hyperactive

behavior

Night waking for longer than 30 minutes                  Excessive masturbation                                 Easily distracted

Hard to wake up in the morning                                 Intentional vomiting/purging                       Difficulty concentrating

Sleepwalking                                                                   Poor self-care/poor hygiene                        Other: _____________

 

 

 

Is there anything else the client would like to share?

What theories and/or models from the book apply to this adolescent and help us understand this transitional time or reporting issue?

 

 

How could someone trying to help this adolescent use theories and research as noted in the text?

 

Discuss common relationship changes that occur in adolescence (parental, friendships and romantic), and compare/contrast to this adolescent’s relationships.

 

Discuss the typical influence of social environments relevant to adolescence to include the role of family, peers, culture, school.  How does this compare to this adolescent’s experiences? ORDER A PLAGIARISM-FREE PAPER NOW

 

 

 

 

 

Complete the in-take form, being sure to include demographic detail about your patient that will provide a reference point for future seminars. Consider and list what models and theories help to understand this transitional time, as related to the reporting issue.  Adolescent Intake Form Paper. What challenges does this present for the character?
Develop a paper to address the following questions:

1. How could someone trying to help this adolescent use theories and research as noted in the text? Use at least 2 major theoretical perspectives that are relevant to this adolescent.
2. In the report based on the adolescent’s age, discuss in depth the key biological and cognitive transitions that the adolescent might be experiencing? Be sure to address how biological changes influence adolescent cognition, emotions and behaviors.  Be sure to explore adolescent decision making, abstract thought, and critical thinking. Would these affect the presenting issues/concerns?

Suggested Length – Two full pages, along with a separate reference page

Adolescent Intake Form Paper