Transcript intake summaries

INTAKE SUMMARIES
(THE INITIAL
INTERVIEW)
FORMS OF SUMMARIES
SOCIAL HISTORIES
 ASSESSMENTS/EVALUATIONS
(PSYCHOLOGICAL AND
CHEMICAL DEPENDENCY)
 PRESENTENCE INVESTIGATIONS
(CRIMINAL JUSTICE)
 INTAKES
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DEFINING INTAKE
SUMMARIES
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AN OFFICIAL REPORT THAT IS
INCLUDED IN THE CASE RECORD.
INCLUDES INFORMATION ON THE
CLIENT FROM THE INITIAL
INTERVIEW. I.E. PRESENTING
PROBLEM, FAMILY BACKGROUND,
FAMILY OF ORIGIN HISTORY, ETC.
MAY INCLUDE TESTING RESULTS
INTAKE GUIDELINES
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STRUCTURE OF THE INTERVIEW
AND REPORT USING THE
FOLLOWING SUBHEADINGS:
IDENTIFICATION
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NAME
AGE
GENDER
RACE/ETHNICITY/CULTURE
MARITAL STATUS & CHILDREN
EMPLOYMENT STATUS
INCOME
REFERRAL SOURCE
PRESENTING PROBLEM
CLIENT DESCRIPTION OF
PROBLEM
 STATUS OF CURRENT
RELATIONSHIPS
 STRESSORS
 WORK HISTORY
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DRUG USE HISTORY
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IDENTIFICATION OF ALL DRUGS
USED (LEGAL AND ILLEGAL)
PAST DRUG USE HISTORY OF ALL
DRUGS (LEGAL AND ILLEGAL)
AMOUNT AND FREQUENCY
TOLERANCE AND WITHDRAWAL
LOSS OF CONTROL
NEGATIVE CONSEQUENCES (LEGAL,
HEALTH, FINANCIAL, WORK OR
SCHOOL, AND RELATIONSHIPS)
MENTAL STATUS
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BEHAVIORAL DESCRIPTION OF
CLIENT DURING INTERVIEW
APPEARANCE
AFFECT
DEPRESSIVE/ANXIETY SYMPTOMS
OBSERVED OR REPORTED
SUICIDE/HOMICIDE IDEATION
THOUGHT DISORDERS
MENTAL STATUS
CONTINUED
ORIENTATION (PERSON, PLACE,
AND TIME)
 ESTIMATED INTELLIGENCE
 SOCIAL CONNECTEDNESS
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PREDISPOSING
FACTORS
SIBLING RANK
 SIBLING RELATIONSHIPS
 SIBLING CD HISTORY
 CLIENT’S RELATIONSHIP WITH
PARENTS
 PARENTAL CD HISTORY
 PARENTAL RELATIONSHIP
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PREDISPOSING
FACTORS CONTINUED
ABUSE HISTORY
 CHILDHOOD TRAUMA
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LIFESTYLE
A DESCRIPTION OF SELF
 A DESCRIPTION OF TYPICAL
DAY
 RECREATION
 HOBBIES AND INTERESTS
 SLEEPING PATTERN
 EATING PATTERN
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TEST RESULTS
SCORING FROM SCREENING
INSTRUMENTS (CD/PSYCH)
 PSYCH(WAIS, WRAT, MMPI)
 CD (MAST, SASSI)
 TENTATIVE INTERPRETATION
BASED UPON TEST DEVICE’S
INSTRUCTIONS
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DYNAMIC FORMULATION
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WORKER’S ANALYSIS AS TO THE
NATURE OF THE PROBLEM
COMPARING SUBJECTIVE AND
OBJECTIVE DATA. INCLUDE
STRENGTHS THE CLIENT BRINGS
TO THE TREATMENT PROCESS.
DIAGNOSTIC
IMPRESSION
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THE WORKER’S IMPRESSION AS TO THE
DSM-IV DIAGNOSIS ON THE CLIENT.
AXIS 1-MOOD/PSYCHOTIC/SUBSTANCE
ABUSE DISORDERS
AXIS 2-PERSONALITY DISORDERS;
COGNITIVE DISORDERS
AXIS 3-PHYSICAL DISORDERS
AXIS 4-STRESSORS
AXIS 5-GAF
PROGNOSIS AND
MOTIVATION
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THE WORKER’S FEELINGS
REGARDING THE POSSIBLE
EFFECTIVENESS OF TREATMENT.
TREATMENT
RECOMMENDATIONS
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TENTATIVE PLAN
* LEVEL OF CARE
* MODALITY OF TREATMENT
* REFERRALS
TREATMENT (LEVEL OF
CARE)
LEAST INTRUSIVE-MEETING
NEEDS
 INCIDENT/ABUSE/DEPENDENCY
 INPATIENT
OR RESIDENTIAL@24/7 CARE
 PARTIAL CARE
@ DAY TREATMENT PROGRAMS
 OUTPATIENT
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A GOOD CD EVALUATION
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SCREENING TOOL
PSYCHOLOGICAL EVALUATION
PHYSICAL EVALUATION
CLINICAL INTERVIEW
SIGNIFICANT OTHER INTERVIEW
DIAGNOSTIC IMPRESSION
TREATMENT RECOMMENDATIONS
INTERVIEW
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CURRENT DRINKING/DRUGGING PATTERN
(HOW MUCH? HOW OFTEN? HOW MUCH TO
HAVE AN EFFECT? NEGTATIVE
CONSEQUENCES? ETC.)
PAST DRINKING/DRUGGING PATTERN
(TIME LINE, CHANGES, TOLERANCE)
SOCIAL/ WORK RELATIONSHIPS
(NEGATIVE CONSEQUENCES)
FAMILY OF ORIGIN (FAMILY CD HISTORY;
CORE ISSUES)
DAILY ACTIVITIES (CHEMICAL USE)
MENTAL STATUS (DUAL DIAGNOSIS)
CD TESTING
(SCREENING) DEVICES
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(M)ICHIGAN (A)LCOHOLISM
(S)CREENING (T)EST
(S)UBSTANCE (A)BUSE (S)UBTLE
(S)CREENING (I)NVENTORY
(W)ESTERN (P)ERSONALITY
(I)NVENTORY
(P)ERSONAL (E)XPERIENCE
(I)NVENTORY
MICHIGAN ALCOHOLISM
SCREENING TEST
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25 ITEM PENCIL AND PAPER
QUESTIONNAIRE
CAN BE USED IN INTERVIEW FORMAT
LIFETIME ALCOHOL-RELATED
PROBLEMS AND ALCOHOLISM
APPROXIMATELY 10 MINUTES TO
TAKE
NO TRAINING REQUIRED TO
ADMINISTER
HAND SCORED
SUBSTANCE ABUSE SUBTLE
SCREENING INVENTORY (SASSI)
SCREENS FOR ALCOHOL AND
OTHER DRUG DEPENDENCY
 EMPIRICALLY TESTED
ACCURACY OF 93%
 15 MINUTES TO TAKE
 SIDE 1- QUESTIONS OBVIOUSLY
RELATED TO SUBSTANCE
MISUSE (FACE-VALID ITEMS)
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SUBSTANCE ABUSE SUBTLE
SCREENING INVENTORY
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SIDE 2 – TRUE/FALSE QUESTIONS
WHICH DON’T NECESSARILY APPEAR
TO BE RELATED TO SUBSTANCE
MISUSE (SUBTLE ITEMS).
SCORING (PROFILE) FORM FOR MALE
AND FEMALE
EASILY SCORED
EASILY USED TO PROVIDE
INFORMATION FOR TREATMENT
PLANNING
SASSI SCALES
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FACE VALID SCALES (FVA AND FVOD)
SYM(SYMPTOMS)
OAT(OBVIOUS ATTRIBUTES)
SAT(SUBTLE ATTRIBUTES)
DEF(DEFENSIVENESS)
SAM(SUPPLEMENTAL ADDICTION
MEASURE)
COR(CORRECTIONAL)
FAM(FAMILY)
RAP(RANDOM ANSWERING
PATTERN)
SASSI SCALES
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FACE VALID (FVA;FVOD)
* ACKNOWLEDGMENT
OF USE INCLUDING
CONSEQUENCES
SYM (SYMPTOMS)
* SUGGESTS CAUSALITY
OAT (OBVIOUS ATTRIBUTES)
* DEGREE OF INSIGHT
SAT (SUBTLE ATTRIBUTES)
* NOT SO OBVIOUS SIGNS OF ABUSE
SASSI SCALES
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DEF (DEFENSIVENESS)
* AVOIDANCE OF ACKNOWLEDGING ANY PERSONAL LIMITATIONS OR FAULTS
* ABILITY TO ENGAGE
* DEGREE OF EMOTIONAL PAIN
SAM (SUPPLEMENTAL ADDICTION
MEASURE)
* INCREASES ACCURACY OF TEST
(COMPARED WITH DEFENSIVE
SCORE)
SASSI SCALES
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COR (CORRECTIONS)
* ASSESS RISK OF LEGAL
PROBLEMS
FAM (FAMILY)
* IDENTIFICATION OF
PEOPLE WHO TEND TO FOCUS
ON OTHER PEOPLE’S NEEDS
RATHER THAN THEIR OWN
RAP (RANDOM ANSWERING
PATTERN)
The Cleveland Criteria: Seven
Dimensions for Making Placement
Decisions
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1. Acute alcohol and/or drug
intoxication and/or withdrawal
potential
2. Physical complications
3. Psychiatric complications
4. Life area impairment
5. Treatment acceptance/resistance
6. Loss of control/relapse crisis
7. Recovery environment
ASSIGNMENT
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PICK A PARTNER TO INTERVIEW
(ROLEPLAY DUI)
GATHER INFORMATION BASED UPON
INTAKE GUIDELINES
ADMINISTER MAST AND SASSI
(SCORE AND INTERPRET)
TYPE UP (SINGLE SPACED) INTAKE
SUMMARY (DON’T FORGET TO INCLUDE THE
RELEASE OF INFORMATION FORM)
TURN IN TESTS ON CLIENT WITH
ASSIGNMENT (I WILL SHRED)