bshs405 r1 intake assessment form
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 last 4 months. Sister and second cousin are threating to kick the client out of the home due to lack of taking medications and paying her bills. Client has lost all her forms of Identification.
2. CURRENT CLIENT INVOLVMENT WITH OTHER AGENCIES
Agency/Person
Phone
Service
Date
Medicaid
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
Sister and second cousin
Social
N/A
Support
Sister and second cousin
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
1
Legal
N/A
Education
Did not graduate high school wants to take test for GED
Occupation
N/A
Finances
N/A
Psychosocial & environmental problems
Bipolar Does not take medications are recommended does not attend her counseling meetings
4. CURRENT MEDICAL CONDITIONS
Condition
Physician
Bipolar
Dr Mark Fritz
5. PREGNANT
YES
Receiving prenatal care?
Treatment medication and counseling
NO
YES
NO
6. PRIMARY CARE PHYSICIAN
Dr Mark Fritz
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
2
7. CURRENT MEDICATIONS
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 last 4 months. Sister and second cousin are threating to kick the client out of the home due to lack of taking medications and paying her bills. Client has lost all her forms of Identification.
2. CURRENT CLIENT INVOLVMENT WITH OTHER AGENCIES
Agency/Person
Phone
Service
Date
Medicaid
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
Sister and second cousin
Social
N/A
Support
Sister and second cousin
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
1
Legal
N/A
Education
Did not graduate high school wants to take test for GED
Occupation
N/A
Finances
N/A
Psychosocial & environmental problems
Bipolar Does not take medications are recommended does not attend her counseling meetings
4. CURRENT MEDICAL CONDITIONS
Condition
Physician
Bipolar
Dr Mark Fritz
5. PREGNANT
YES
Receiving prenatal care?
Treatment medication and counseling
NO
YES
NO
6. PRIMARY CARE PHYSICIAN
Dr Mark Fritz
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
2
7. CURRENT MEDICATIONS