Adolescent Psychology
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casestudy2.docxStudent Name: Joe Student
Adolescent Intake Form
ADOLESCENT/CLIENT’S INFORMATION
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NAME: |
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AGE: |
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GENDER |
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RACE/ETHNICITY |
|_| Caucasian/White |_| Hispanic |_| Native American |_| African American/Black |_| Asian |_| Biracial |_| Other |
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who referred THE CLIENT? |
|_|Self |_| Parent/Family Member |_|Teacher |_|Friend |_|Other: _____________ |
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What problems/ISSUES DOES THE CLIENT PRESENT WITH? |
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WHEN DID THESE CONCERNS BEGIN? |
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Is Treatment Court Ordered? |
|_|Yes |_|No If yes, why:_____________ |
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Employment information: |
|_| Full-time Student |_| Part-time Student |_| Employed |_| N/A
Name of Employer: ____ Job Title: ______
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LEGAL HISTORY: |
Has the child been charged with a crime? |_| Yes |_| No Is the child on probation? |_| Yes |_| No If yes, please explain : |
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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 |
SCHOOL FUNCTIONING
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High School Grade |
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Past / Present truancy issues |
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Expulsions |
Yes |_| No |_| If yes, explain number and reason(s): __________
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Suspensions |
Yes |_| No |_| |
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Repeat Grades |
Yes |_| No |_| |
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Any special accommodations made for student? |
|_| No |_| 504 Plan |_| Special Education / IEP If yes, explain:
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SOCIAL, PLAY AND RECREATION
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Describe the child’s recreational interests (if any). |
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Briefly describe significant relationships (many/few friends, best friend, romantic relationships, etc.) |
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Caregiver/HOUSEHOLD information:
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Who is primary caregiver of the adolescent? |_| Parent |_| Other Relative |_| Guardian |_| OTHER If other, explain:
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Number of household members: Who lives in the home with the child (parent(s), siblings, others, etc.):
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Who lives in the home with the child (parent(s), siblings, others, etc.
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Brief description of living arrangements |
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Are there any custody/visitation arrangements? Please describe. |
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Describe the child’s family, cultural and religious connections. |
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Mental Health History:
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|_| No previous therapy (Skip to next section of form) |
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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: __________________________________
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|_| Inpatient Treatment/Psychiatric Hospitalization Previously hospitalized: |_| Yes |_| No |_| N/A Multiple Hospitalizations: |_| Yes ___________
Dates of treatment: _____________________________________ Reason for treatment: __________________________________
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Has the child experienced grief and or loss, or significant trauma? |_| Yes |_| No Explain: ___________ |
MEDICAL INFORMATION:
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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 |
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Currently Prescribed Medications |
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: _____________
4/6/2021
4
4/6/2021
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Is there anything else the client would like to share? |
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What theories and/or models from the book apply to this adolescent and help us understand this transitional time or reporting issue?
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How could someone trying to help this adolescent use theories and research as noted in the text?
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Discuss common relationship changes that occur in adolescence (parental, friendships and romantic), and compare/contrast to this adolescent's relationships.
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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?
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Case Study: Section One
**There will be two major content areas here, but you will want to use headings (or not) as appropriate for your specific case. The only required heading for this is the one above (Case Study: Section One). Use the rubric to ensure that you touch on all of the areas necessary.
References
Put your References for Section One ONLY here.
Case Study: Section Two
**There will be five major content areas here, but you will want to use headings (or not) as appropriate for your specific case. The only required heading for this is the one above (Case Study: Section Two). Use the rubric to ensure that you touch on all of the areas necessary.
References
Put your References for Section Two ONLY here.
Case Study: Section Three
**There will be six major content areas here, but you will want to use headings (or not) as appropriate for your specific case. The only required heading for this is the one above (Case Study: Section Two). Use the rubric to ensure that you touch on all of the areas necessary.
References
Put your References for Section Three ONLY here.
Case Study: Section Four
**There will be five major content areas here, but you will want to use headings (or not) as appropriate for your specific case. The only required heading for this is the one above (Case Study: Section Two). Use the rubric to ensure that you touch on all of the areas necessary.
References
Put your References for Section Four ONLY here.
