Case Diagnosis

INTAKE AND ASSESSMENT INFORMATION

NAME STATE STREET

PHONE Mail CELL

Interviewing Professional

Treating Professional

Referral source: ( Self ( Court ( DCFS ( Probation/Parole ( Friend ( Other:

Today’s Date

1) IDENTIFYING INFORMATION:

Last Name

First

Preferred name if different

( Female

( Male

2) PRESENTING PROBLEM AND SYMPTOMATOLOGY:

( Do you at times have any depression moods?

( Do you have disturbances in your sleep patterns?

( Do you find yourself to lose interest quickly?

( How often do you forget things?

( Have you encountered issues of guilt in excess with self?

( Do you find it easy to involve yourself in risky behavior often?

( Do you recall any anxiety attacks?

( Do you consider your irritability to increase often?

( Have you or do you have hallucinations experiences?

( Do you find yourself to be suspicious of almost everything you encounter?

( Have you had experiences where you feel you have excessive energy?

( In delicate matters, do you consider yourself to have high worry levels?

3) DEVELOPMENTAL HISTORY:

( Have you ever had any abnormal body movements in the past?

( Are there cases of developmental delays that have to do with you?

( Have you ever been involved in past social and non-social issues?

( Do you have issues when it comes to behavioral control?

( Have you ever had unusual ways of walking while growing up?

( Have you ever encountered any issue or difficulties related to speech?

( Apart from issues to do with difficulties during delivery were there issues that arose during post-natal developments?

( Have you ever participated in any sports and related therapy?

( Do you recall or have any record of any past medications taken during your early childhood?

( Have you had Criminal versatility issues?

( Do you consider yourself to have few, and well defined goals?

( Do you find yourself in situations that you see it hard to accept responsibility?

Under social issues:

( Have you; at any moment or period have numerous marital relationships?

( Have there been in any issues of abuse in the past?

( At what age did you start to have sexual involvements and engagements?

( State what kind of relationship did you have? ( Romantic; awareness of safe sex; sexual orientation)

4) EDUCATIONAL HISTORY:

( To what level of education have you reached? ( Primary, secondary, tertiary)

( Are you affiliated to any religious affiliation (Islam, Christianity, Buddhism, Judaism, atheist, others), and have you obtained knowledge in any of the religions?

( Have you ever assumed any leadership roles in either institutions of education that you have attended?

( Have you had issues to do with self-centered impulsivity?

( Kindly can you state the number of leadership roles you have assumed in education institutions that you have attended.

5) FAMILY HISTORY: Parents married, never married, divorce etc. ● Custody issues ● Adopted ● Siblings ● Who lives in the home ● Supports ● Include any psychiatric illnesses

( Has anyone in your family die prematurely?

( Do have any cases of disabilities in your family, including psychological?

( Are your parents married, divorced or never even got married?

( Have there been custody issues in relation to your family?

( Has your family ever been involved in any adoption activities?

( How many siblings do you have?

( Who do you live with, at home?

( Do you receive any kind of support from your family?

( What kind of support has the family been offering to you?

( Has there been any case of psychiatric illness in your family?

( If there has been, kindly name the psychiatric illness case in your family

6) MEDICAL HISTORY

( Have you ever had any form of allergies?

( What is your current weight? ……

( What is your height? …….

( Have you had any previous medical diagnoses and prescriptions?

( List all current prescription medications and how often you have them……….

( Have you undergone any medical trials in the past?

( Have you been hospitalized in the near past?

( If yes, for what illness?

( Have you ever tried to harm yourself with no intent to kill yourself or even have such thoughts on you?

( In previous history have you been engaged in any form of aggression?

( Do you recall any previous therapeutic assistance on you?

( Have you had any thoughts or made an effort to commit suicide?

( Have you had any issues to do with bedwetting in the past?

7) ATHLETIC PERFORMANCE HISTORY :

( Do you and have you participated in sporting activities?

( In relation to your participation in athletic activities, do you have any therapy history?

( Have you had past injuries while undertaking physical exercises?

( Have you undergone any previous injuries assessments in the past?

( Do you consider your training place to be safe?

( Do you trust those who you train or do sporting with?

( Do you have fear or worry that your colleagues you do sporting and training with may harm each other?

SUBMITTED BY: ………………………………………………………………………………

Date:………………………….