UCI Abnormal Psych Stress Management Intake Form for Assignment #1

Please fill out the following information for your “client” (either yourself or a friend)

Please use this form and add in the details requested so that we can see all the labels and
sections and more easily grade your work. (note – there are a few “instructions” sections
that are directed at you – the intake worker – you should leave those out of your final
submission)

REMEMBER to please take (or have your “client” take) the stress and coping skills
inventory (borrowed from New York State Schools) that is in the same module as
this assignment. You will need to score these and write up a short report. On a
separate page, please document the results of the stress and coping skills assessments
that your “patient” took and summarize what the results mean – use a professional
tone as if you were writing up the results of an assessment for your client, please use
our own words and do not just copy and paste from the assessment instrument)

1. Patient Information:
 Name: Anonymous student (no name needed)
 Age: 20
 Identified Gender: male
 Year in College and expected graduation date: 2023
 Major: engineering
 Units taken this quarter: 8
 Relationship Status: roommate
 Current living arrangements: None
 Current employment status: None

2. Short narrative summary of current health and well being status:

(reason for intake) (please don’t include overly personal information, this is just a
class assignment!)
3. Stressors: Please circle all of the following that apply and indicate the level of stress it
causes this student (you or your friend):

 Academic demands (e.g., workload, exams, grades) Level of Stress:

 Financial pressures (e.g., tuition fees, living expenses) Level of Stress:
 Family issues (e.g., relationships, illness, conflicts) Level of Stress:
 Relationship issues (e.g.; romantic partners, conflicts) Level of Stress:
 Social pressures (e.g., friends, ) Level of Stress:
 Time management (e.g., balancing school, work, and personal life) Level of Stress:
 Health concerns (e.g., physical or mental health issues) Level of Stress:
 Work/employment stress/concerns (eg; job stress) Level of stress
 Housing concerns (e.g.; roommate issues, housing access) Level of stress:
 Future uncertainties (e.g., job prospects, career path) Level of Stress:
 Recent traumas or losses (e.g.; deaths, accidents, trauma, etc) Level of Stress:
 Other (list) Level of Stress:

3. Coping Strategies: Please circle all of the following strategies that you/your friend
uses to cope with stress:

 Exercise
 Healthy eating
 Ensuring adequate sleep
 Spending time with friends and family
 Relaxation techniques (e.g., meditation, deep breathing)
 Seeking emotional support (e.g., talking to a counselor, therapist, or trusted individual)
 Time management strategies (e.g., scheduling, prioritizing tasks)
 Participating in sports
 Engaging in hobbies
 Attending fun events and/or traveling
 Positive self-talk
 Other (please specify):
 Use of alcohol or drugs to cope. (how often/amount)

4. Impact of Stress:

 How does stress affect you? (e.g., physically, emotionally, academically)

 Have you noticed any changes in your behavior or mood as a result of stress? Please
explain.

5. Support System:
 Who do you turn to for support when you are feeling stressed?
 Do you participate in any faith based organizations or other groups that you consider to
be helpful in supporting you.
 Do you have a significant other or best friend that you feel is a positive support?
 Any issues with your support systems actually creating more stress?

6. Additional Comments:

 Is there anything else you would like to add about your stress levels or coping strategies?

7. Summary of Results from STRESS ASSESSMENT – (short report)

1. On a separate page, please document the results of the stress and coping skills
assessments that your “patient” took and summarize what the results mean –
use a professional tone as if you were writing up the results of an assessment
for your client, please use our own words and do not just copy and paste from
the assessment instrument)

8. Treatment Plan: (you will follow the directions on the next page and fill out the stress
management plan for your client.
 STRESS MANAGEMENT TREATMENT/ACTION PLAN
Note to patient: Stress has been identified as having a negative impact on your life, below is an
action plan that is developed specifically for you that will allow you to tackle and overcome the
stressors in your life. Because you are a UCI student, UCI resources are being listed for stress
management tools. All of these resources are free or very low cost and I have included detailed
descriptions of each resource and my recommendations for the most effective plan for you to
access them to help reduce your stress.
(directions for intake worker (you can/should leave these directions out of your submission) –
please research and list five separate free or very low cost stress management/stress coping
resources on the UCI campus that your “patient” can access that will help them manage their
stress. Personalize these so that they match the needs of THIS student (which might be you)
based on the results of their assessment and intake. You may NOT refer them to counseling,
medical or psychiatric services, all stress coping resources should be related to helping manage
STRESS and each should be from a different organization on campus. Only ONE of the resources
can be virtual. Please do not address mental health or physical health or medications/vitamins
or nutrition, please focus on STRESS. Please list each resource, give excellent details about
what that resource offers (in your own words) and where/when it is located, WHY this
resource will be helpful to this student, and then state a plan for your “patient” to access and
utilize each resource. (be realistic, lol!). Please include a live link to where the student can find
more information about each resource (the program’s website) I have provided an example
below, please do NOT use my example or this exact same resource in your plan. Please make sure
that you are referring the student to professional resources on campus, don’t just give advise –
give specific details about specific programs that the student can access on campus. You may
NOT copy from me (or any other source) or use the exact same resource that I have used in my
example (yoga in Aldrich park)

UCI Stress Management Resource EXAMPLE (this is just for the student intake
worker -don’t copy or include this section in YOUR submission and please do not use
this exact same resource for your client)

Description of resource. Location of Resource. Link to resource information.

When is this resource offered/available: (for example: Free Campus outdoor Yoga –
daily, varying times. I recommend the class on T/Th in Aldrich park behind the career
center from 12-12:50 p.m., although there are evening times as well in a separate
location. (https://my.campusrec.uci.edu/Program/GetProgramDetails?
courseId=24cd2cf6-62bf-4c9a-ad6d-a77c022170e9&semesterId=c5c637ee-7db2-4186-
af4a-1959bb1dabeb)
 Reason that this resource will be helpful (& expected outcome) (for example:
Because you listed headaches and sleep difficulties and mentioned that you are not
exercising much, I feel that practicing some form of relaxation will be an excellent way to
improve your overall physical health, improve your sleep and help you learn the tools to
turn your mind off as needed. Yoga is also an excellent form of gentle exercise, so this
should benefit your overall fitness as well. And spending time in an outdoor setting can
significantly reduce stress and improve mood, so the outdoor setting of this class is ideal.
I would expect that the regular, ongoing practice of yoga will reduce your overall stress,
improve your sleep and help you feel more calm and focused on a daily basis. Yoga
classes are also something that you should be able to access during the summer in your
hometown once you leave campus, making this an excellent long term coping strategy.)

Plan for patient to access this resource (for example, you might state “I recommend
that you attend the free outdoor yoga class a minimum of twice a week on T/Th at noon
in Aldrich park and then continue this attendance for the rest of the quarter. Given your
current class schedule, this appears to be an ideal time for you. I would suggest
attending with a friend as socializing can also help to reduce stress and attending with a
friend helps to maintain motivation. As mentioned, I would also encourage you to
continue the practice of yoga on a regular basis over the summer as well by accessing
yoga classes in your hometown.

Below are FIVE UCI RESOURCES that can be utilized to help reduce your overall
stress with directions for how to access them:

UCI Stress Management Resource #1:

Description of resource. Location of Resource. When is this resource offered/available?
Reason that this resource will be helpful (& expected outcome)
Plan for patient to access this resource (how often, for how long, etc)

UCI Stress Management Resource #2:

Description of resource. Location of Resource. When is this resource offered/available?
Reason that this resource will be helpful (& expected outcome)
Plan for patient to access this resource (how often, for how long, etc)

UCI Stress Management Resource #3:

Description of resource. Location of Resource. When is this resource offered/available?
Reason that this resource will be helpful (& expected outcome)
Plan for patient to access this resource (how often, for how long, etc)

UCI Stress Management Resource #4:

Description of resource. Location of Resource. When is this resource offered/available?
Reason that this resource will be helpful (& expected outcome)
Plan for patient to access this resource (how often, for how long, etc)

UCI Stress Management Resource #5:

Description of resource. Location of Resource. When is this resource offered/available?
Reason that this resource will be helpful (& expected outcome)
Plan for patient to access this resource (how often, for how long, etc)