Intake Assessment Form Revised 
Wildwood Case Management Unit
Intake Assessment Form
Client Name Claire Jones
# 13456789
D.O.B. 6/1/1982
Unit # 2
Date of Assessment 6/25/2015
1. PRESENTING PROBLEM (Functional impairment, symptoms, background)
Claire is a 33 year old female concerned about being evicted from her apartment because she recently lost her employment. She is also concerned about not being able to find her Medicaid card and other forms of identification to obtain the medication for her bi-polar disorder.
2. CURRENT CLIENT INVOLVMENT WITH OTHER AGENCIES
Agency/Person
Phone
Service
Date
N/A
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
Claire lives with her older sister and cousin.
Social
N/A
Support
N/A
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
Has an extensive juvenile record for offenses of disorderly conduct, petit theft, and resisting arrest.
Education
9th grade education
Occupation
Claire was fired recently from her job at a 24 hour convenience store for behavioral issues and for not arriving on time for work.
Finances
N/A
Psychosocial & environmental problems
Claire's environment is highly stressful she is constantly arguing with her sister and cousin in regards to her not being able to pay rent or take her medication this is causing a discord in her home environment. 4. CURRENT MEDICAL CONDITIONS
Condition
Bi-polar disorder
5. PREGNANT
YES
Receiving prenatal care?
Physician
Treatment
Dr. Thomas
Anti-depressant
NO
YES
NO
6. PRIMARY CARE PHYSICIAN
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
Name/Dosage
antidepressant
Prescribed by
Dr. Thomas
Condition bi-polar disorder
Side effects
mood swings
Medication allergies none 8. RELATIONSHIP RISK
Intake Assessment Form
Client Name Claire Jones
# 13456789
D.O.B. 6/1/1982
Unit # 2
Date of Assessment 6/25/2015
1. PRESENTING PROBLEM (Functional impairment, symptoms, background)
Claire is a 33 year old female concerned about being evicted from her apartment because she recently lost her employment. She is also concerned about not being able to find her Medicaid card and other forms of identification to obtain the medication for her bi-polar disorder.
2. CURRENT CLIENT INVOLVMENT WITH OTHER AGENCIES
Agency/Person
Phone
Service
Date
N/A
3. ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS
Family
Claire lives with her older sister and cousin.
Social
N/A
Support
N/A
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
Has an extensive juvenile record for offenses of disorderly conduct, petit theft, and resisting arrest.
Education
9th grade education
Occupation
Claire was fired recently from her job at a 24 hour convenience store for behavioral issues and for not arriving on time for work.
Finances
N/A
Psychosocial & environmental problems
Claire's environment is highly stressful she is constantly arguing with her sister and cousin in regards to her not being able to pay rent or take her medication this is causing a discord in her home environment. 4. CURRENT MEDICAL CONDITIONS
Condition
Bi-polar disorder
5. PREGNANT
YES
Receiving prenatal care?
Physician
Treatment
Dr. Thomas
Anti-depressant
NO
YES
NO
6. PRIMARY CARE PHYSICIAN
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
Name/Dosage
antidepressant
Prescribed by
Dr. Thomas
Condition bi-polar disorder
Side effects
mood swings
Medication allergies none 8. RELATIONSHIP RISK