Background Information On The Addiction

Review the sample intake form provided as a guide.
Select one addiction for which you will write a paper.

4- to 6-page paper that includes the following:

Background information on the addiction you have chosen to write about. Use at least 23 sources of information that describe how to assess your chosen addiction.
Elements of an intake process that would elicit relevant information on an individual demonstrating signs of this addiction, including the following:

Two addiction evaluation measures that might be appropriate for that individual, and explain why you chose them
Five questions you would ask to assess for addiction
Five questions you would not ask, and explain why these questions would be inappropriate

Sample Intake Form: Not for actual use.
PRESENTING COMPLAINT:__________________________________________________________________________
Psychological:
DEPRESSION: Appetite Change Depressed Affect Anhedonia Sleep Disturb. Low Energy Conc./Memory
Social Withdrawal Suicidal Thoughts Hopelessness Helplessness Crying Onset ___________________________
Recurring: Y/N
ANXIETY: Ruminating Nervousness Worry Panic Attack Avoids Situations PTSD Onset: ____________________
SLEEP QUALITY: Good Difficulty Falling Asleep Wakes up early Nightmares Onset: ______________________
OTHER: Anger Irritability Mania ___________________________________________________________________
Guilt Perfectionism//Eating Abuse/Trauma Addiction: Gambling Pornography Shopping
Family history of psychological problems: Y/N
If yes, please describe: ___________________________________________________________________________________
Current Stress: ______ Stressors: ____________________________ Coping: _____________________________________
Self-Esteem: __________________________________________________________________________________________
Appearance: Well-groomed Unkempt Unusual Other: _____________________________________________
Cooperation: Cooperative Indifferent Dependent Defiant Manipulative Guarded Hostile
Affect: Normal Flat Blunted Constricted Labile __________________________________________________
Speech: Normal Slow Too detailed Pressured Incoherent Slurred Perseverating
Mood: Normal Depressed Anxious Euphoric/Manic _____________________________________________
Thought Content: Coherent Illogical Delusions Hallucinations___________________________________________
Orientation: Person _____ Place______ Time______
Judgment: Intact Impulsive Immature Impaired __________________________________________________
Motor: Relaxed/calm Restless Agitated Tense Tremors Tics ______________________________________
Attention/Concentration: Normal Mildly Distractible Majorly Distractible
Employment: Title: ______________________ Tenure: ________ In field: ______ Work supportive: Y/N ___________
_____________________________________________________________________________________________________
Education: Highest Grade: _______________________ Special Ed: Y/N Held back: Y/N LD: Y/N _______________
Medical:_________________________________________________ Allergies: Food____________ Meds_____________
Meds: ________________________________________________________________________________________________
Hit in Head/Knocked Unconscious:Y/N __________________________________________________________________
Current Exercise: Y/N Type: ____________ Frequency: ____________ Duration: ____________ Onset: ___________
Previous Counseling:
Type: ______________ Date: ______________

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