bshs405 r1 intake assessment form Essay

1195 Words Oct 26th, 2015 5 Pages
Wildwood Case Management Unit
Intake Assessment Form
Client Name Claire
# 01
D.O.B. 6-27-1981
Unit # 01
Date of Assessment 8/15/2015
1. PRESENTING PROBLEM (Functional impairment, symptoms, background)

Claire: 33 year old female lives with sister and second cousin. client was terminated from last job for
issues with behavioral as well as not being punctual for her arrival to work. client was diagnosed with
bipolar disorder at the age of 18. client has revised care as well as many different medications to
help stabilize her moods has also been on an antidepressant to treat the bipolar. Client has cycles
where she does not take her medication. she currently has not been attending her counseling
sessions or paying her personal bills for the
…show more content…
Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions

4

Perceptions/hallucinations
illusions
hallucinations
Suicide risk
none ✔ slight
moderate

depersonalization

derealization

significant

extreme

no plan

plan (describe)

significant

extreme

no plan

plan (describe)

N/A

Violence risk
✔ slight
none

moderate

N/A
Judgment
✔ impulsive
✔ immature
✔ impaired
intact
age appropriate
mile
moderate
severe
Insight
✔ limited
intact
very limited
fair
none
aware if current disorder
understands personal role in problems
Sensorium
✔ alert
drowsy
stupor
obtundation
coma
Memory
✔ impaired
intact
immediate recall
remote
amnesia
type of amnesia
Intelligence
✔ below average
✔ unable to establish
average
above average
Interviewer summary of findings (add details where appropriate)
Claire has been off her medications for the last 4 months. Claire has not been employed for the
last 4 months. The client has bipolar disorder has erratic behavior since she has not been on
her medications. She mentally unstable at this time and is in need of care to be…

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