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Withdrawn YES NO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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