Intake Form & Questions

Marital Status: (circle) Single Married Separated Divorced

Email: [email protected]

Address: 3334 N. 56th Street Scottsdale, AZ 85000

Phone: (602)555-4444

Work Status: (Circle all that apply)

1. Currently employed as a clerk of the court________________________

2. Looking for employment as __________________________________________

3. Involved with local government agency to find employment_________

4. Going to college at ___________________________________________

5. Obtaining vocational training at_________________________________

Any formal diagnoses: Mild depression. High Cholesterol

Any medications (dose and frequency): Lipitor 50 mg; Paxil 30 mg _________

Specific concerns: (Provide reasons for today’s visit. Please be specific about work life, school, and family influences):

I’ve been having trouble sleeping and focusing at work lately. My boss suspects I might be addicted to pain meds, so she said I had to meet with you or be fired. I think she’s threatened by me and wants me out of her department, but I can’t prove that. I was in a car accident a year ago and had surgery on my shoulder. I was put on Percocet for the pain. I went through physical therapy but my shoulder never healed right. My doctor stopped prescribing painkillers even though I’ve had pain every day since the accident. I turned to heroin because I could no longer get painkillers. Heroin is cheap and it works. That’s so unlike me. I never used drugs before when I was younger. I’ve never even smoked a cigarette. I was able to continue working until I failed a random drug test at work. I was suspended until I could pass the test again. I did and now I am back at work. My coworkers talk about me behind my back. I tend to work and eat alone more than I used to. My family says they are worried about me because I am losing a lot of weight. My mom and older sister taught me how to take care of myself. They instilled in me a strong work ethic. We’re Italian, so family is important to me. They’re all I have. They keep me centered. I’ve always been independent, so it’s been hard for them to see me so thin and weak. I want to get better so they won’t worry about me. I’m here for suggestions on what to do. I no longer use heroin, but I am still in constant pain. I can’t lose my job even though it’s very stressful. I have to sit and listen to court proceedings all day. I have 10 years left before I can retire and I can’t lose my pension. I need help.

Any Family History of Mental Illness: Not that I know of __________

Possible Services Desired: (Circle all that apply)

**This client may be passive at first and may become combative if pressed about addiction issues. She may appear lethargic and depressed due to possible drug abuse or withdrawal. The interviewer will need to use effective engagement strategies to obtain more information. The interviewer will need to be ready to suggest social services to the client.

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