Initial intake assessment
Presentation of the problem:
Why are you seeking help at this time?
What are you struggling with the most?
Motivation and support:
How does your family feel about the possibility of you coming to our Center?
Why do you want intensive help now instead of 30 days ago or a month from now?
If 100% means 100% committed, how committed are you to letting go of your eating disorder and recovering? (Please give your answer as a percentage).
History of previous treatment:
Start at the beginning with your first treatment and list the dates, facilities and professionals from whom you received the treatment. (inpatient / outpatient dates; doctor / therapist names and phone numbers)
How have you felt about the treatment you have received?
Has it helped you? If I say yes, in what ways?
If it hasn’t helped in the past, why not?
General non-psychiatric medications you are currently taking:
History from the beginning to the present of psychiatric medications:
Are there any medications that have helped you significantly in the past?
Does any member of the immediate family take psychiatric medications? What family member and what medication (s)?
Are the medications you are currently taking helping you?
If you are not currently taking medication, are you willing to consider taking psychiatric medication?
(Answer the following questions regarding your family of origin and your extended family.)
Are you married, single or divorced?
How many children are there in your family of origin?
What is your birth order in your family of origin?
What is your parents’ marriage like?
Do you have a family history of emotional, physical, or sexual abuse?
Do you have a family history of criminal activity?
Do you have a family history of bipolar or psychotic illness?
Do you have a family history of psychiatric hospitalizations?
Do you have a family history of alcohol or substance abuse?
Describe your relationship with your mother:
Describe your relationship with your father:
Describe your relationship with your spouse if you are married:
Do you have any current medical problems or conditions?
Have you had a serious accident? If yes, please explain.
Have you been hospitalized for any reason? If yes, please explain.
Patient history and current situation:
Have you experienced serious losses in your life? What, who, when?
Have you ever experienced a traumatic event in your life?
Are you under a lot of stress right now?
What are the current stressors in your life?
Have you ever experienced, recently or in childhood, any sexual, physical, emotional or verbal abuse? If yes, please describe:
History of eating disorders:
When did you first notice feeling depressed?
Describe the history of your depression:
When did you start having eating disorder problems?
How did your eating disorder start?
Tell me how your eating disorder developed over time:
What is your current height and weight?
What is the most it has weighed and when?
What is the least it has weighed and when?
Have you ever abused or used over-the-counter diet pills, methamphetamine, laxatives, or diuretics? If so, when and what?
Do you get drunk and purge yourself? How much food and how often?
What is your estimated daily caloric intake at this time?
Describe your exercise habits:
How do you feel about your body?
What is the amount of weight you have gained or lost in the last 60 days?
Have you ever been arrested? If so, please explain.
Have you ever stolen? If so, please explain.
Have you ever been arrested for DUI?
Have you ever abused someone in any way?
Educational Background / Concerns:
Have you ever been diagnosed with an intellectual disability, a learning disability, or ADHD?
Have you ever been to special education or resource programs at school?
How did you do in school with the content of the class, the children and the teachers?
Are there areas of difficulty or exceptional achievement in the school?
Current educational activities / work history and current employment status:
What is your current GPA?
What was your GPA in high school?
Special interests in school or major:
Do you currently have a job? If so, where do you work and what do you do?
What are your future educational and vocational goals?
Do you live with your immediate family? (Yes or no)
Geographically, how close is your closest immediate family member?
How often do you visit your family on the phone or in person?
When you are with them, what is it like?
State of mind:
You have work?
Have you recently lost a job?
Can it work at work?
Are you currently attending school?
How are you doing in your classes?
Do you miss classes or are you falling academically? Please explain:
Can you take care of yourself?
Can you take care of your children?
Are you socially active or isolated? Please describe:
POTENTIAL FOR SUICIDE / PERSONAL INJURY None, mild, moderate, severe, current suicidal ideation, intention, number of previous attempts: current suicide plan: Personal injury / mutilation: current, past (describe):
POTENTIAL FOR VIOLENCE none, mild, moderate, severe, verbally aggressive, physically aggressive. Please describe:
IMPAIRED REALITY TEST / DISSOCIATIVE EPISODES List deficits: memory, delusions, judgment, avoidance, confusion, suspicion, auditory hallucinations, visual hallucinations, perceptual disturbance
ALTERATION IN MOOD / AFFECTION incongruous, tearful, lack of concentration, worthlessness, hopelessness, feelings of guilt, labile, angry, withdrawn, dejected, euphoric, disinterest, trouble making decisions, lack of motivation, affection: others:
MOOD CHANGES Describe:
DYSFUNCTIONAL SLEEP PATTERNS none, early morning awakenings, frequent awakenings, excessive sleep, difficulty falling asleep, sleepless nights
DYSFUNCTIONAL EATING PATTERNS none, bulimia (describe), anorexia (describe), changes in appetite, recent weight loss / gain, obsessive thoughts, or compulsive patterns / rituals (describe)
ANXIETY none, moderate, severe, panic, symptoms, fears or phobias
SUBSTANCE ABUSE none, alcohol (amount, frequency, last drink), drugs (type and frequency), prescription / OTC:
HISTORY OF ABUSE none, sexual, physical, emotional, describe:
Diagnostic prints (preliminary):
DSMIV, Axis I, II, III, IV, V, Medical Concerns, Current Stressors, Current GAF, Highest GAF Last Year:
Recommendations and treatment needs:
Inpatient and Outpatient Day Program
Possible Medication Needs:
Possible medical consultation needs:
Possible testing / evaluation needs:
Additional comments or concerns:
by Michael E. Berrett, PhD