NEW BEGINNING Counseling Services

Shanda A. Caniquie LMHC, BSW

42 Rivero Street, Belize City Belize
Ph: 224-2100063 Fax: 501-6301474
E-mail: scaniquie@student.bridgew.edu

Comprehensive Clinical Assessment & Intake-Adult

Name: __________________ DOB: __________ Date of Assessment:________

Health Insurance Carrier Name: _________________________ Policy Number:_______________________

Gender Expression: Please check one or more options that reflects your gender

⸋Woman ⸋Man ⸋Non-binary ⸋Transgender

⸋Intersex ⸋Gender non-conforming ⸋Other

Ethnicity: ⸋White ⸋Black ⸋Biracial ⸋Hispanic ⸋Asian ⸋Other _________

Culture:_________________________________ Primary Language: ___________________________

Other Languages:_____________________________ Religious Beliefs: ____________________________

Presenting Problem/Reason for Referral: (Describe history and symptoms, behavioral and functioning needs, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

What brings you to our center today?

___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

How did you learn about this center:_____________________________________________________________________

Check all that apply)

Source of Information: ⸋Person/client ⸋Parent/Guardian ⸋Referral source ⸋Relative/friend ⸋Other: _____________
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult

Mental Health Screening Questionnaire

1. Has person ever heard voices no one else could hear or seen objects or things which others could YES NO
not see?
2. Has person ever been depressed for weeks at a time, lost interest or pleasure in most activities, had YES NO
trouble concentrating and making decisions?
3. Has person ever experienced any strong fears (e.g. heights, insects, animals, dirt, attending social YES NO
events, being in a crowd, being alone, etc.)?
4. Has person ever given in to an aggressive urge or impulse, on more than one occasion that result in YES NO
serious harm to others or led to the destruction of property?
5. Has person ever felt that people had something against him/her, without them necessarily saying YES NO
so, or that someone or some group may be trying to influence his/her thoughts/behaviors?
6. Was there ever a period in person’s life when s/he spent a lot of time thinking and worrying about YES NO
gaining weight, becoming fat, or controlling his/her eating?
7. Has person ever had a period of time when s/he was so full of energy and ideas came very rapidly, YES NO
talked nearly non-stop, moved quickly from one activity to another, needed little sleep, or believed
s/he could do most anything?
8. Has person ever had spells or attacks when s/he suddenly felt anxious, frightened, uneasy, sweaty, YES NO
rapid heartbeat, s/he was shaking, trembling, dizzy, unsteady, as if s/he could faint?
9. Has person ever had persistent, lasting thought or impulse to do something over and over that YES NO
caused considerable distress and interfered with normal routines, work, social relations?
10. Has person ever lost considerable money through gambling or had problems at work, school, with YES NO
family/friends as a result of gambling, overeating, shopping, sexual appetite, etc.?
Additional Comments:  N/A
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Substance Use History
Substance Age Date Pattern of Use Consequences of Use
(Use other side for additional of of (For substances used, include  No consequences reported
frequency, amount and route of ingestion.  Consequences do not suggest
information as needed) first Last use If no use, please write “NONE”. Remember substance use disorder
Drug of Choice: use to summarize any USE below in Summary of
 Consequences suggest substance
_____________ Use box)
use disorder
ETOH Specify: Check all that apply:
Alcohol Uses more than intended of for
longer period of time.
OPIOIDS Specify: Unsuccessful efforts to control
or cut down use.
Large amount of time spend
COCAINE (blow, powder) obtaining, using or recovering
(includes crack cocaine) from use.
AMPHETAMINES Craving to use.
(includes methamphetamine) Recurrent use resulting in
problems at work, home or
BENZODIAZEPINES (Benies)
school.
Continued use despite recurrent
SEDATIVES/HYPNOTICS
social/interpersonal problems
related to use.
CANNABIS/HASHISH /WEED
Curtailing important activities in
favor of use.
HALLUCINOGENS (LSD, Magic
Use despite potentially
mushroom)
hazardous outcomes.
Continued use despite
PCP (angel dust, killer weed)
knowledge that use causes
physical/psychological problems.
CAFFEINE
Tolerance increase and/or
OTCs (over the counter meds) decrease.
Withdrawal symptoms
OTHER: Total # of check marks: _____

Summary of use: No use

(For persons with positive use history: Narrative must include duration of longest time abstinent and what helped the person stay
abstinent during that time, cultural/environmental factors influencing use, whether the person had overdosed on any drugs
including how many times.)

Describe Social Media use including # Hours/day:

 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult

Risk of Exposure to Infectious Diseases

Person reports a history of behaviors or circumstances that has potentially exposed person to Infectious
diseases (e.g. prostitution, anonymous sex, IVDU):  Yes  No

Person reports having been diagnosed with an infectious disease (e.g. HIV, HepC, TB):  Yes  No
*The Infectious Disease Risk Assessment must be completed if the person answered ‘yes’ to either of the above questions
Trauma History (Abuse, Neglect, Violence, Sexual Assault, Drug Overdose)
Description of Traumatic Event(s) None Disclosed Check all that apply: Trauma was experienced and/or
witnessed by client.
Types of Trauma Year Person’s response to trauma

Is the person currently experiencing and/or witnessing neglect/abuse/violence/sexual assault/potential overdose? NoYes
If Yes, describe:

Additional Mandated Report Required?  None

 Department of Children and Families  Disabled Person’s Protection Commission  Elder Affairs  Other: _______________
Additional Comments:
Medication Information
(Include psych meds, non-psych meds, prescriptions, OTC, herbal, dietary supplements, etc.)
 Check here if no medication is being reported by the person served.
 Check here if using the Medication Addendum form to report medications.
Medication Rationale/ Dosage/route Reported side- Adherence Prescriber
Condition /freq. effects (WA= with assistance)
 Yes  No  WA
 Yes  No  WA
 Yes  No  WA
 Yes  No  WA
 Yes  No  WA
 Yes  No  WA
Comments on Medications (include what medications have worked well previously, any adverse side effects, why person doesn’t take meds as
prescribed and/or which one(s) the person would like to avoid taking in the future):

Additional Medical Information

Date of last Well-Child visit with Pediatrician/Adult Physical with PCP: ___________________________________
If client is female, is client currently pregnant:  Yes  No
For women who are pregnant, include whether prenatal care is being provided and whether pregnancy affects the woman’s
participation in treatment:_______________________________________________________________________________ _
FOR CURRENT HEALTH HISTORY AND RELATED INFORMATION, REFER TO MEDICAL HISTORY IN MEDICAL SECTION.
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Past Mental Health and/or Substance Abuse Treatment History
 None Reported (skip this section and go to next page)
Type of Service Dates of Service Reason Name of Provider/Agency Completed
 Yes  No
 Yes  No
 Yes  No
 Yes  No

Risk Assessment
PLANS, MEANS, AND INTENTIONS Yes No Refused- Time Period Comments
unable
Have you actually had any thoughts of killing yourself?
Have you been thinking about how or what way you might do this? (means)
Do you think you will act upon these thoughts while in treatment here?
Have you ever attempted or started to attempt suicide when other people were
around, like at home with parents, in a hospital, or in a group home with staff?

Assessment of Current Level of Harm to Self: (check one in each area)

Risk Status 1. Client’s suicide risk is higher than that of the typical client at this level of care. ***
2. Client’s suicide risk is about the same as that of the typical client at this level of care.
3. Client’s suicide risk is lower than that of the typical client at this level of care.
Risk State 1. Client is at a higher than usual risk for dying of suicide due to current life-circumstances. ***
2. Client is at a lower than usual baseline risk for dying of suicide.
*** Persons at a higher Risk Status and/or higher Risk State need to complete a Life Safety Plan***
History of harm to others?  No  Yes If Yes, Details including dates, means, lethality, etc.:

Legal Status
Legal Guardianship of an Adult: No Yes Name: _________________________________ Phone No.: _________________
Relationship to Person:_____________________________________
Type: Full Guardianship Roger’s Guardian Healthcare Proxy Permanent
Temporary (explanation):____________________________________________________________________________
Conservatorship: No Yes Name/Agency: ______________________________________ Phone No.: _________________
Relationship to Person:______________________________________
Rep. Payee: No Yes Name/Agency: ___________________________________________Phone No.: _________________
Relationship to Person: _____________________________________
If under 18 Parent/Guardian Information:
Mother’s Guardianship:  Joint  Full  Legal Only  Physical Only  None
 Other: _________________________________________________________________________________________
Father’s Guardianship:  Joint  Full  Legal Only  Physical Only  None
 Other: _________________________________________________________________________________________
Other Person/Agency Guardianship (Name the person/agency and describe):
________________________________________________________________________________________________
The Parent(s)/Guardian(s) are able and willing to participate in services:  N/A
 Yes  No: ______________________________________________________________________________________
Strengths of the Parent(s)/Guardian(s):  N/A

Preferences of the Parent(s)/Guardian(s):  N/A

Comments:None
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Current and Past Criminal/Legal Involvement
List all previous charges (criminal & civil) and their disposition:  N/A

Types of Charges Date of Charges

Name and Phone Number of Court and Probation/Parole Officer: N/A ______________________________________

Domestic Relations Court Involvement (i.e. Custody, Protective Services, Restraining Order):
None Current Past Comment: ___________________________________________________________________

Child Support Enforcement Orders: None reported

Comments:None

Military History
 No military service reported  Current active service  Veteran Branch ____________________
Type of Discharge: N/A Date of Discharge: ___________________ Honorable Dishonorable Conditional
Reasons for type of discharge: ______________________________________________________________________________

Combat Experience: (where, when) __________________________________________________________________________

List and Medals, Honors and/or Citations:

Comments:None
Education History
Highest Degree Attainment:  None
GED HS Diploma Vocational Training:____________ College Degree: ______________ Graduate Degree: _____________
Currently Enrolled:  N/A
School: _________________________________Year/Program:______________School Contact:______________________________
Current Letter Grade:___________ School Achievement: Average  Below average  Above average
Educational Interests/skills:
Is the person served satisfied with his/her current educational situation? Yes No
Person’s status in school is in good standing Yes No N/A
Does the person want to pursue additional education? Yes No Uncertain
History of learning difficulties: None reported
Performance/Behavioral Problems related to: Mental Health Issues Substance Use Issues Both
Learning Disability: None Past History Current: _________________________________________________
Developmental Disability: None Mild Moderate Severe Profound
Intellectual Functioning: Average  Below average Above average
Literacy level: Illiterate Basic Skills Proficient Other: _____________________________________________
Person’s Preferred Learning Style: Visual/spatial Auditory/musical Verbal/written Physical Social
Logical/mathematical Solitary/self-study other: ________________________________________
Barriers to Learning: None reported Attention Difficulties Cognitive Difficulties English is a Second Language
Hearing Impaired  Deaf  Truancy/Absenteeism Reading Difficulties Writing Difficulties Visually Impaired  Blind Speech
Impaired Victim of Bullying  Bullying  Other: ______________________
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Current Status: Client has need of Assistive Technology in the provision of services:  No  Yes (Please elaborate:)

Employment/Vocational History
Check here if person is Child/adolescent and not in work force, then skip to next section.
Person’s current employment: full time part time Other: __________________________________________
unemployed/seeking unemployed/not seeking Last date worked: _______________________________________
Person served is satisfied with job: Yes No N/A Person’s job is in jeopardy: Yes No N/A
Person’s capabilities/areas of interest:

Educational/vocational training needs:

Summary of past/present positions/skills: never in work force

Name of most recent Employer: N/A ____________________________________________________________________

Reason(s) for leaving job(s) in last five years: N/A
Lacked transportation Did not get along with boss/supervisor Terminated Laid off
Did not like work hours Babysitter/child care problems Mental Health problems
Did not like working conditions Did not like job duties Medical problems
Did not get along with co-workers Pay too low Substance Abuse problems
Maternity leave Temporary employment Other: ______________________
Attendance: Above average Normal Tardiness Absenteeism
Performance: Exemplary Good Average Below average
Comments:None
Financial History
Current financial situation: comfortable/living w/i means occasional struggles often struggles
financial struggles are a major source of stress
Contributors to financial status: friends/family SSI SSDI Food Stamps Disability: $___________
other: ______________________________________________________________________________________
Comments:None

Living Situation
Rent Own Temporary Housing Residential Program Nursing/Rest home Relative/Guardian’s Home Foster Care Homeless
with Friend/Family Homeless in shelter No Residence Other: _________________________________________
At risk of losing current housing: Yes No
Satisfied with current living situation? Yes No
Is there anything significant about where you live that impacts your mental health?_________________________________________
Family and Social Support History
Family of origin: Raised by: _____________________________ Persons in household: ___
Number of siblings: _____ Place in birth order: ______________________ List significant relationships in family of origin (parents,
siblings, close grandparents, caregivers, etc.)
Name Relationship Still living? ______________________________________ ________________________

Marital Status: Single Married Divorced Widowed Gender Identity: Male Female Transgender Other________
Sexual Preference: Males Females Both Other_______________ Sexual Concerns: None ______________
 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Family History and Relationships: (Distinguish who else lives in the home with an *, and include any use of alcohol, tobacco or other
drugs by family members: types of and responses to previous treatment. Use additional page or other side if needed.)

Name Age Relationship Medical/MH/SA History Relationship Quality

Parental/Familial Obligations: None ___________________________________________________________________________

Developmental History and Status

Pre-natal exposure to drugs/alcohol No Yes____________________________________________________________________
Birth complications No Yes__________________________________________________________________________________
Milestones Met on Time? (talking, walking, etc) Yes No___________________________________________________________
Current limitations to ADL’s No Yes___________________________________________________________________________
Community Supports (provide a brief description of each)
Describe Friendships: Describe Social Interactions: Describe Other Meaningful Activities:

Recommended Level of Care

None:  No treatment needed/wanted at this time  Referral to self-help only
Outpatient:  Mental Health  Substance Abuse Co-occurring  Medication Assessment
 Outpatient Home-based Treatment  CSP  TM  IHBS
Intensive Outpatient:  Substance Abuse Day Services (IOP, SOAP)  PHP  IHT
Inpatient:  Detox  Hospitalization  Residential  Inpatient Substance Abuse and/or Mental Health
Person’s Served Strengths, Needs, Abilities and Preferences
(Skills, talents, interests, aspirations, protective factors, preferences for course of treatment)
Strengths
Needs
Abilities
Preferences
Advance Directives Has one and will bring in.  Wants one, given referral Discussed purpose of AD
Further Evaluations Needed:  None Indicated  Psychiatric  Psychological  Neurological  Medical
 Educational  Vocational  Visual  Auditory  Nutritional  Substance Use Assessment Other:

Monthly Reports Must Be Sent To:  None  DCF  Probation Other:

 NEW BEGINNING Counseling Services
Comprehensive Clinical Assessment & Intake-Adult
Interpretive Clinical Summary
Summarize your clinical opinion. What are the factors that led to the needs areas and your plan to address them?
Include co-occurring and co-morbid disabilities/disorders and differential diagnosis information. Interpret needs and causes of
symptoms/disorders. Draw conclusions and make treatment recommendations. (Use other side if needed)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

DSM5 Diagnosis(es)
[Include Alpha AND Numeric Information with relevant subtypes, specifiers and severity]
Principle:
Additional: N/A
Additional: N/A
Psychosocial/environmental problems (include ICD-10 code): N/A

__________________________________________________________ __________________________
Clinician Signature / Credentials Date
__________________________________________________________ __________________________
Client or Parent/legal guardian Signature (If applicable) Date

*This assessment was hybridized from Arbour Counselling Services’ and Foundations Mental Health Services’ comprehensive clinical assessment
documents*