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Elements of an intake process that would elicit relevant information on an individual demonstrating signs of this addiction, including the following:

Two addiction evaluation measures that might be appropriate for that individual, and explain why you chose them

Five questions you would ask to assess for addiction

Five questions you would not ask, and explain why these questions would be inappropriate

Sample Intake Form: Not for actual use.
PRESENTING COMPLAINT:
__________________________________________________________________________
Psychological:
DEPRESSION: Appetite Change Depressed Affect
Anhedonia
Sleep Disturb.
Low Energy Conc./Memory
Social Withdrawal Suicidal Thoughts Hopelessness Helplessness Crying
Onset ___________________________
Recurring: Y/N
ANXIETY: Ruminating
Nervousness Worry Panic Attack Avoids Situations
SLEEP QUALITY: Good
OTHER: Anger
Guilt
Difficulty Falling Asleep
Irritability
Wakes up early
PTSD
Onset: ____________________
Nightmares Onset: ______________________
Mania ___________________________________________________________________
Perfectionism//Eating
Abuse/Trauma
Addiction: Gambling
Pornography
Shopping
Family history of psychological problems: Y/N
If yes, please describe: ___________________________________________________________________________________
Current Stress: ______ Stressors: ____________________________ Coping: _____________________________________
Self-Esteem: __________________________________________________________________________________________
Appearance: Well-groomed
Unkempt
Unusual Other: _____________________________________________
Cooperation: Cooperative
Indifferent
Dependent
Affect: Normal
Flat
Speech: Normal
Slow
Blunted Constricted
Too detailed
Mood: Normal Depressed
Thought Content: Coherent
Pressured
Anxious
Illogical
Labile
Defiant
Manipulative
Guarded
Hostile
__________________________________________________
Incoherent
Slurred
Perseverating
Euphoric/Manic _____________________________________________
Delusions
Hallucinations___________________________________________
Orientation: Person _____
Place______
Time______
Judgment: Intact
Immature
Impaired __________________________________________________
Impulsive
Motor: Relaxed/calm
Restless Agitated
Tense
Attention/Concentration: Normal Mildly Distractible
Tremors
Tics ______________________________________
Majorly Distractible
Employment: Title: ______________________ Tenure: ________ In field: ______ Work supportive: Y/N ___________
_____________________________________________________________________________________________________
Education: Highest Grade: _______________________ Special Ed: Y/N
Held back: Y/N
LD: Y/N _______________
Medical: _________________________________________________ Allergies: Food____________ Meds_____________
Meds: ________________________________________________________________________________________________
© Laureate Education Inc.
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Hit in Head/Knocked Unconscious: Y/N __________________________________________________________________
Current Exercise: Y/N Type: ____________ Frequency: ____________ Duration: ____________ Onset: ___________
Previous Counseling:
Type: ______________ Date: ______________ # Sessions: ___________ Response: _____________________________
Type: ______________ Date: ______________ # Sessions: ___________ Response: _____________________________
Suicide Attempt: Y/N __________________________________________ Homicide Attempt: Y/N __________________
Spiritual Life: _________________________________________________________________________________________
Substance Abuse:
Nicotine: Y/N Frequency: _______________________________________________________________________________
Alcohol: Y/N _____________________________________________ Past: ______________________________________
Drugs: Y/N _________________________________ Past: ____________________________________________________
Legal: _______________________________________________________________________________________________
Notes: _______________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
© Laureate Education Inc.
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