Wildwood Case Management Unit Intake Assessment Form Client Name: Rick D.O.B September 15, 1952. Date of Assessment 31/8/2012 PRESENTING PROBLEM (Functional impairment, symptoms, background) Rick was referred for treatment by his wife. He has been experiencing stress following the loss of his job. He is worried on how to support his family without a job. Rick has a history of alcohol abuse and because he is jobless his drinking habits have increased. With his age, he is worried that getting another job might be futile to him. CURRENT CLIENT INVOLVEMENT WITH OTHER AGENCIES N/A ASSESSMENT OF LIFE CIRCUMSTANCES OR CHANGES IN THE FOLLOWING AREAS Family He is the Head of his household at the time of referral. Rick is 59 years and has been married for 40 years; he has three children Social Alienated from friends Support Currently Rick is supported by his wife Legal N/A Education N/A Occupation N/A Finances Mr. Rick experiences financial problems Psychosocial and environmental problems Alcohol abuse Unemployment He believes that his new boss does not like him and that is why he laid him off CURRENT MEDICAL CONDITIONS N/A PREGNANT ( ) YES(â—) NO Receiving prenatal care? ( ) YES (â—) NO PRIMARY CARE PHYSICIAN N/A CURRENT MEDICATIONS Name/DosageN/APrescribed ByN/ACondition N/A Side Effects N/A
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