Clinical Intake Outline Child/Adolescent

Clinical Intake Outline Child/Adolescent Patient Identification Child/Adolescent Name: Medical Record #: Date of Birth: Person(s) Interviewed and relation to child: Date(s) of Assessment: Clinician: Clinician # (if applicable): Instructions to Clinician: Before conducting the clinical interview, carefully review the client information form and other application materials. Expand and clarify the information gathered from those materials on this form. It is not necessary to copy information from other sources onto this document but to record new information and clarification of other materials. Reason for Referral: Referral source: Why seeking treatment/assessment at this time? List major problems/reasons for referral, in parents own words/terms (to be operationalized as specific behavioral targets/objectives on following pages): http://www.smbs.buffalo.edu/centers/adhd/default.php

Intake Outline Page 2 History of Problems and Treatment (from client information form; query for accuracy and expand if necessary; e.g., When first diagnosed with ADHD?) Personal and Social Information 1. Who lives in the home?: a. Who is/are the primary caretaker/s? b. Who is/are the primary disciplinarian/s? c. What are the interactions like between the child and other adults in the home? (including stepparents, grandparents, boyfriends, etc.) d. What are the responsibilities of the other adults in the home for the child? School Information (The information in this section should come primarily from the client information form, school records, and meeting with the child s teacher/s. Information that is incomplete from the application packet should be queried in this section.) 1. Current placement of child in school (get information from client information form and rest of application packet) Grade: # children in class: # teachers/aides: Does the child have a current IEP or 504 plan? (describe/attach copy) Nature of special class placement: Describe how placement occurred How well is the child doing in the current classroom?

Intake Outline Page 3 2. History of school placement [get information prior to intake from application packet (child's school schedule, CBCLs)] Grades retained: Typical grades: Ever expelled or suspended? Describe circumstances: In special placement in the past? Describe how placement occurred and how long in placement: 3. Testing [get information from application packet (e.g., CBCLs)] and get signed release to obtain results if parent does not bring copy. Any intelligence/achievement testing? What tests have been given and dates in the past? Most recent date of intelligence or achievement testing: Where tested? What were results? 4. Current teacher/school report (Has teacher, principal, counselor, etc. complained to parents of or noted a need for improvement in child's behavior or academic performance? Describe complaints; consult impairment ratings etc. for information)

Intake Outline Page 4 5. School's child management procedures (e.g., school's punishments for inappropriate behavior, and reward programs for good behavior; how have programs worked?) Consistent classroom rules and structure: Praising appropriate behaviors/ignoring minor inappropriate behaviors: Instructional modifications: Daily report card (DRC): Homework assignment book: "If...then" contingencies: Point or token reward system: Response-cost system: Group or classwide contingencies: Time out: School-wide programs: Use now Used in past Outcomes 6. Parent Report of teacher/school assets and liabilities a. Teacher s motivation/willingness for involvement in program b. Principal/other administrator s motivation/willingness for involvement in program c. Relationship between the teacher/school administration and parents d. How often do the parents and teacher/administration communicate: By note: By phone: Face-to-face? 7. Teacher Report of teacher/school assets and liabilities a. Teacher s motivation/willingness for involvement in program b. Principal/other administrator s motivation/willingness for involvement in program c. Relationship between the teacher/school administration and parents d. How often do the parents and teacher/administration communicate: By note: By phone: Face-to-face?

Intake Outline Page 5 Presenting Problems (complete one page for each problem; continue on back if necessary). Begin by giving a brief ABC explanation of behavior and explain that you will be asking about antecedents, behaviors and consequences, all defined very specifically and objectively. Problem (define specific behavioral target from previous page): When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) How often does the problem occur, and in what settings? What is the intensity/severity of the behavior? -Home -School -With peers -Other (describe) What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)? What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and what have been the results? How consistent have the parents reactions been? What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the problem? What are short-term and long-term consequences? No Problem Does not need intervention Extreme Problem Definitely needs intervention

Intake Outline Page 6 Problem (define specific behavioral target from previous page): When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) How often does the problem occur, and in what settings? What is the intensity/severity of the behavior? -Home -School -With peers -Other (describe) What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)? What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and what have been the results? How consistent have the parents reactions been? What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the problem? What are short-term and long-term consequences? No Problem Does not need intervention Extreme Problem Definitely needs intervention

Intake Outline Page 7 Problem (define specific behavioral target from previous page): When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) How often does the problem occur, and in what settings? What is the intensity/severity of the behavior? -Home -School -With peers -Other (describe) What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)? What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and what have been the results? How consistent have the parents reactions been? What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the problem? What are short-term and long-term consequences? No Problem Does not need intervention Extreme Problem Definitely needs intervention

Intake Outline Page 8 Problem (define specific behavioral target from previous page): When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) How often does the problem occur, and in what settings? What is the intensity/severity of the behavior? -Home -School -With peers -Other (describe) What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)? What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and what have been the results? How consistent have the parents reactions been? What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the problem? What are short-term and long-term consequences? No Problem Does not need intervention Extreme Problem Definitely needs intervention

Intake Outline Page 9 Problem (define specific behavioral target from previous page): When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) How often does the problem occur, and in what settings? What is the intensity/severity of the behavior? -Home -School -With peers -Other (describe) What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)? What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and what have been the results? How consistent have the parents reactions been? What effect does the problem have on the child and those around him/her; what is the level and type of impairment associated with the problem? What are short-term and long-term consequences? No Problem Does not need intervention Extreme Problem Definitely needs intervention

Intake Outline Page 10 Current treatment (see client information form, query for confirmation, clarification, and expand if necessary) Psychoactive medication Prescribing physician: Medication and dosage Condition received for: # times taken each day Date last seen: # days/week taken How long on this dosage? School-days 7 days School days + as needed School-days 7 days School days + as needed School-days 7 days School days + as needed School-days 7 days School days + as needed School-days 7 days School days + as needed Any medication side effects? Psychosocial (describe nature of treatment in detail): Classroom interventions (describe nature of interventions in detail, including parents role): School psychologist/counselor: Other:

Intake Outline Page 11 Parents child management procedures: a. Describe parents typical punishment for inappropriate behavior and rewards for good behavior (include information on consistency across time, settings, and parents). Complete table and expand: Use now Used in How does/did it work? House rules Praising appropriate behaviors/ignoring minor inappropriate behaviors Use of commands Use of reprimands Loss of privileges Daily report card (DRC): "If...then" contingencies Spanking/physical punishment Point or token reward system: Response-cost system: Time out: past b. Can the parent and child/adolescent communicate effectively with each other? How well can they solve problems together without getting angry? c. How well does the parent monitor or keep track of the child's/adolescent s whereabouts, including what the child is doing, who the child is with, where the child is? d. What is the parents background with behavioral parent programs - previous parent training classes, reading, etc.? What are the parents' main sources of parenting knowledge? Motivation for treatment, willingness to change (separately for child, mother, father, etc.):

Intake Outline Page 12 How does everyone in the home get along with one another? (include relevant individuals in the child s home and each set of custodial parents/homes) a. Parents (Do parents agree on discipline strategies? Are parents sharing care of the child in a mutually satisfactory manner? Is there frequent marital conflict?): b. Mother/s and child: c. Father/s and child: d. Siblings and child: e. Friends and child: f. Others (specify): Are the biological parents divorced? a. How long since the divorce? (see client information form) Who has custody of child; what are custody arrangements: -legal? practical? (e.g., how often does the child see each parent)? b. What is the degree of contact with the parent not in the home? c. Does this parent argue with the interviewed parent regarding appropriate discipline and expectations for the child? Do the parents get along with each other or is there conflict? Are transitions from one parent's home to another difficult? (see client information form for some information)

Intake Outline Page 13 d. Has the child experienced a subsequent divorce? (If so, repeat questions c-d for that parent) Does child/adolescent have his/her own room or does he/she sleep with others? What is the physical environment of the home? (e.g., apartment or house? Is there a yard to play in? Where does the child play?) Child-parent interactions a. How much time does each parent spend with the child? b. Do the parent and child get to spend some enjoyable time together each week? Social Stressors a. Financial (include information about family financial status) b. Work-related Parents occupations and work hours (include information about day care arrangements): c. Transitions (How many different parent figures has the child had? How many times has the child moved? Most recent transition?) d. Relatives e. Medical f. Other (include regular commitments/obligations of parents and hours (i.e., school, troop leader, care of elderly relative, volunteer work)

Intake Outline Page 14 Rating of Overall Stressor Severity (DSM IV) 1 2 3 4 5 6 7 None Mild Moderate Severe Extreme Catastrophic Unspecified Social Supports (relatives, neighborhood, vocational) Medical and Developmental History (review client information form and health history questionnaire; the clinician should inquire to clarify that information is correct and to get detailed information about anything abnormal or problems reported) 1. Pregnancy (see health history questionnaire) 2. Developmental milestones (walk, talk, toilet trained) 3. Hospitalizations/surgeries (see client information form and health history questionnaire) 4. Medical problems (include any recent symptom complaints such as headaches, stomachaches, etc.; see client information form and health history questionnaire) 5. Medications (only medications not listed for ADHD treatment) 6. Allergies to medicine or adverse drug reactions (see application form and health history questionnaire)

Intake Outline Page 15 7. Childhood illnesses (see application form and health history questionnaire) 8. Enuresis/encopresis (see item 108 on parent CBCL) 9. Tics (unusual movements) (see item 46 on parent CBCL and health history questionnaire; make sure that parents understand this question by defining or demonstrating if necessary) 10. Seizures or spells (do they interrupt behavior) (see client info. form and health history questionnaire) 11. Eating disorders (obesity, anorexia, bulimia) 12. Physical limitations (see client information form) 13. Special diet 14. Vision/hearing problems (if tested, when? see health history questionnaire) 15. Confirm physician's name, phone number (how long/often have they been seeing this physician and any previous physicians) (see page 2 of the application form)

Intake Outline Page 16 If appropriate, explore the following in more detail (current and past): Sexual problems Sleep problems Post-traumatic stress disorder Adjustment disorders Sexual activity Trouble with the law Physical or sexual abuse Suicidal ideation and behavior Tobacco, alcohol, or other drug use/abuse

Intake Outline Page 17 Functioning Level (Axis V from DSM IV) Past GAF Score: Highest level of functioning in the past year for at least a few months Current GAF Score: Level of functioning at the time of the assessment Significant Family Medical and Psychiatric History Clinician is responsible to ensure comprehensiveness, accuracy, and limitations of the information provided on the client information form. Information on the client information form must therefore be reviewed, clarified, and confirmed. In addition, the clinician is responsible for documenting the following: # of biological mother's sister(s): # of biological mother's brother(s): # of biological father's sister(s): # of biological father's brother(s): Impact of Patient's Problems on the Child/Adolescent, the Family, the School, and Other Support Systems (e.g., effects of problem on the family as a unit, e.g., on child's relationships with siblings, parents, on parents' relationship with one another) Mental Status of Child and Parents (clinician observations) 1. Appearance and General Behavior 2. Mood and Affect 3. Rate and pattern of speech and thought 4. Content of speech and thought 5. Perception 6. Cognitive functions 7. Insight into problems

Intake Outline Page 18 Patient/Family Strengths Recommendations for Further Evaluation Additional history (specify wherever possible the sources of additional history) Diagnostic assessments (recommendations for laboratory studies, neuropsychological testing, educational needs, etc.) Problem list and recommendations (note each area of concern followed by proposed treatment recommendations) DSM-IV Multiaxial Diagnostic Formulation I. Clinical Disorders, Other conditions that may be a focus of clinical attention II. Personality Disorders, Mental Retardation III. General Medical Conditions IV. Psychosocial and Environmental Problems Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Other psychosocial and environmental problems V. Global Assessment of Functioning