Form38 - [FORM 38-Use the top of this page for your...

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[ FORM 38 —Use the top of this page for your letterhead.] Intake Summary and Case Formulation Where space is insufficient, use an asterisk and write the information on additional pages. A. Basic information Client: Date: ID #: Purpose of this intake: q New client evaluation q Readmission; previous intake on q Consultation; copy to be sent to q Reevaluation or review q Other purpose: B. Dynamics of difficulties Presenting complaint(s): Thoughts, behaviors, emotions Stressors Acute/chronic Strengths/resources C. Present level of functioning/limitations/impairment (describe specific impairments at left, and rate degree of functional impairment at right with GAF number [100 = none, 70 = little, 30 = significant, 10 = incapacitated] or use descriptors): Area of functioning GAF rating 1. School/work functioning: 2. Intimate relationship/marriage: 3. Family/children: 4. Social relationships: 5. Psychological/personal functioning: 6. Other areas: (cont.) FORM 38. Intake summary and case formulation (p. 1 of 3). From The Paper Office . Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
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Intake Summary and Case Formulation (p. 2 of 3) D. Assessment conclusions
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Form38 - [FORM 38-Use the top of this page for your...

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