Baker University Counseling Center

Initial Assessment
Client
Name:

Intake Date(s)

DOB

I.

Identification Data (age, sex, year in school, major, marital status, living situation)

II.

A. Presenting Concerns(s)
1. Academic
7. Anxiety
2. Career
8. Alcohol/Substance Use
3. Relationship
9. Adjustment to School
4. Family
10. Physical Abuse
5. Medical/Somatic
11. Sexual Abuse
6. Depression
12. Eating/Weight

13. Impulse Control

14. Sexual Concerns
15. Legal
16. Coping with Daily Life, Leisure,
Financial, Housing, or Self Care
17. Social Skills
18. Other _____________________

B. Primary Concerns _______________________

C. Risk Assessment Low=1 to High=5 or No present concern (NPC)
1. Dangerousness to self ___________
3. Drug/Alcohol Use/Abuse _____________
2. Dangerousness to others _________
4. History of Suicide Attempts Yes No
If yes, how many and when ____________________________________________________________
D. Current Medications ____________________________________________________________
Medical Problems ______________________________________________________________
E. Current Alcohol and Drug Use ____________________________________________________________
F. Current Tobacco/Caffeine Use ____________________________________________________________
G. Current Sleeping/Eating Habits
H. Legal History ____________________________________________________________

III. Problem Description / Problem History

________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________

IV. Current life Stressors

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________

IV. Personal History (psychiatric treatment [if so, what did you like and what did you not like], medical treatment)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

V. Family History (size of family, any psychiatric treatment, medical history, suicide/homicide, drug/alcohol abuse)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________

VI. Clients Self-Assessment (strengths and liabilities)

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________

VI. Clients Behavior and Appearance

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________

1. Orientation

Fully Oriented ___Yes

___No

2. Behavior
___ Appropriate ___ Agitated ___ Psychomotor Slowing

10. Diagnostic Impression

Code
Description
Axis I

___________ ______________________________

3. Memory (Intact)
Recent ___ Yes ___ No
Remote ___ Yes ___ No

Axis II ___________ ______________________________

4. Estimated Intellect
___ Below Avg. ___ Avg. ___ Above Avg.

Axis IV Problem with:

___ Primary Support Group
___ Social Environment
___ Educational
___ Occupational
___ Housing
___ Economic
___ Access to Health Care
___ Interaction with Legal
___ Other Psychosocial/Environmental

5. Judgment
___ Appropriate ___Impaired
6. Affect
___ Appropriate ___ Inappropriate ___Labile
7. Mood
___ Euthymic
___ Depressed ___ Anxious ___Euphoric ___Irritable
8. Thought Process
___ Psychotic Symptoms
___ Delusions
___ Paranoia
___ Phobias
___ Obsessions
___ Worthlessness/Guilt
___ Suicidal thoughts
___ Homicidal thoughts
___ Appropriate
9. History of CNS trauma and seizure disorder
(head injury, loss of consciousness)
____________________________________________

Axis III ___________ ______________________________

Axis V GAF Score ______

Axis VI: Strengths
Prognosis
1
2
3
excellent good
fair

Time Frame___________
4
poor

5
guarded

11. Recommended Services

____ Intake
____ Extended Evaluation
____ Individual
____ Psychiatric Evaluation
____ Couple
____ Physical Evaluation
12. Referrals
Campus
____ Student Affairs
____ Faculty Member
____ Financial Aid
____ Dorm/Living
____ Other ________

Noncampus
____ Hospital
____ Other Mental Health
____ Private Care
____ Drug/Alcohol
____ Other ________

VIII. Counselors Conceptualization of Presenting Problem and Related Issues

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
______________

Treatment Goals:______________________________________________________________________________________________
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_

Therapist_____________________________________________________

Date___________________________________

Supervisor (if applicable)_________________________________________

Date___________________________________