Intake Assessment Form
Intake Assessment Form
As you become more familiar with the various forms of psychopathology, you will realize that collecting an accurate and specific history of a client's psychosocial profile is a key element that can assist in establishing a diagnosis.
In this assignment, complete the following:
•Develop an intake assessment form for your future clinical practice. The form should provide the necessary information for you to make a competent diagnosis.
•Your intake assessment form should be written as a three- to four-page questionnaire with questions to aid in gathering relevant information to do the following:
◦Form diagnostic impressions
◦Complete a differential diagnosis
•Your questionnaire should tap into key areas of developmental, social, emotional, medical, behavioral, psychological, and athletic performance functioning.
•Your intake assessment form should contain the following components:
◦Identifying information
◦Presenting problem
◦Symptomatology
◦Developmental history
◦Educational history
◦Family history
◦Medical history
◦Athletic/performance history
•Develop specific questions to obtain detailed information about these components. You are welcome to review intake assessment measures you have access to professionally, or you can conduct research to locate and view examples of intake assessment forms.
•The level of detail within these sections is up to your discretion as well as the inclusion of additional components (such as checklists or diagrams).
Note: This assessment tool will become an essential part of your professional portfolio. When meeting with clients or performing consulting services, completing an assessment form enables you to organize and categorize pertinent data essential for diagnostic success. After developing your own intake assessment form, you will be given opportunities later in the course to use it to practice diagnostic exercises.
By the due date assigned, submit your intake assessment form in Microsoft Word document format to the Submissions Area. Name your file SP6005_M2_A2_lastname_firstinitial.doc.
All written assignments and responses should follow APA rules for attributing sources.
Maximum Points
Questionnaire phrases are coherent, comprehensive, and sufficient for gathering of information to form diagnostic impressions and to complete a differential diagnosis.
26
Questionnaire is appropriately and accurately designed to cover the given key areas and elicit appropriate responses in each of the given components.
26
Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources, displayed accurate spelling, grammar, and punctuation.
4
Total:
56