Dallas County Public Defender’s Office
Dallas County Public Defender’s Office
Mental Health Division
Intake Assessment Form
(ATTORNEY- CLIENT PRIVILIGE INFORMATION)
Date _____________________________
Client Name______________________
DOB_______________________________
SSN_______________________________
GENERAL
a. Behavior
Cooperative/Composed YES NO
Disruptive YES NO
Withdrawn YES NO
Restless/Anxious YES NO
b. Appearance
Appropriate YES NO
Disheveled YES NO
Poor hygiene YES NO
Inappropriate (seductive, outlandish) YES NO
c. Facial Expression
Unremarkable YES NO
Sad YES NO
Angry YES NO
Confused YES NO
Fearful YES NO
Pleasant YES NO
Unresponsive YES NO
d. Posture
Unremarkable YES NO
Erect YES NO
Rigid YES NO
Limp YES NO
Stooped YES NO
e. Gait
Normal YES NO
Rigid YES NO
Shuffling YES NO
Ataxia YES NO
f. Motor Activity
Normal YES NO
Agitated/Fidgeting YES NO
Retarded YES NO
Tremor/Tic YES NO
AFFECT
Within normal limits YES NO
Flat YES NO
Blunt YES NO
Labile YES NO
Constricted YES NO
Tearful YES NO
Indifferent YES NO
Inappropriate YES NO
MOOD
Fearful YES NO
Angry YES NO
Euphoric YES NO
Labile YES NO
Anxious YES NO
Sad/Depressed YES NO
4. INTELLECTUAL FUNCTIONING
Consciousness
Alert YES NO
Clouded YES NO
Fluctuating YES NO
Stupor YES NO
Apathetic YES NO
Orientation
Time YES NO
Place YES NO
Person YES NO
Circumstance YES NO
Memory Recall
DOB YES NO
Address YES NO
Phone # YES NO
Year YES NO
Day of week YES NO
President of the U.S. YES NO
General Knowledge
Consistent with education YES NO
Superior YES NO
Above average YES NO
Average YES NO
Below Average YES NO
Poor ` YES NO
5. THOUGHT PROCESS
Speech
Spontaneous YES NO
Verbose YES NO
Pressured YES NO
Rambling/Fragmented YES NO
Confused/Incoherent YES NO
b. Language
Normal YES NO
Baby Talk YES NO
Odd Intonation YES NO
6. THOUGHT CONTENT
Delusions YES NO
Paranoia YES NO
Auditory Hallucinations YES NO
Visual Hallucinations YES NO
Suicidal Thoughts YES NO
Homicidal Thoughts YES NO
7. Have there ever been any of the following treatments received?
In-Patient psychiatric hospitalizations YES NO
Psychotropic medications (past) YES NO
Psychotropic medications (present) YES NO
Any outpatient psychiatric treatment YES NO
List hospitalizations, medications, and treatments____________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. What is the substance abuse history?
Alcohol Abuse/Dependence YES NO
Illegal/prescription drug abuse (current)YES NO
Illegal/prescription drug abuse (past) YES NO
History of drug/ETOH TX or AA YES NO
Family history of CD issues YES NO
What substances, duration and amount___________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Mental Health History
Have you ever attempted suicide? YES NO
Have you ever had a sleep disturbance YES NO
Are you having a sleep problem now? YES NO
Is there a history of any type of abuse? YES NO
Please provide details for any of the above____________________________________
_____________________________________________________________________________________________________ _______________________________________________________________
10. Are there any medical health problems such as:
Hypertension YES NO
Diabetes YES NO
Heart Disease YES NO
Kidney Failure YES NO
Please list history and all medication taken for the above disorders_______________________________________________________________________
__________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
11. Is there a support system? YES NO
Family YES NO
Friends YES NO
Social Clubs YES NO
Gang affiliation YES NO
List all family members, children and current or ex-spouse(s)_______________
____________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________
12. Employment/Insurance
Have you ever been employed? YES NO
Are you currently employed? YES NO
Do you receive SSI? YES NO
Do you receive Medicare? YES NO
Do you receive Medicaid? YES NO
Do you have any other insurance YES NO
Do you have any other source of income? YES NO
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
13. Living Arrangements
Are you currently homeless? YES NO
Do you rent a place to live? YES NO
Do you own a place to live? YES NO
Does anyone live with you? YES NO
Are there any stressors in your current home environment?
YES NO
Please give any details________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
14. What is your greatest need right now?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
15. General Impression:________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature__________________________________________
Date____________________
................
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