Fabricated Intake Report

You will complete a fabricated intake report for this assignment. This will be uploaded as a word document, you should use the “Intake Assessment Form” found on pages 460-467 in the book (Summers, Nancy (2016). Fundamentals of case management practice: Skills for the human services (5th ed). Belmont, CA: Brooks/Cole.) to guide your report.

This form is NOT was is required. Instead, use this form to help you create an organized report of your fabricated client’s first visit with you. It may be helpful to ask a peer/friend/family member to MAKE UP answers as you interview him/her. Do you provide real life situations in this report.

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Your full intake report will be based upon APA guidelines. Additionally, please complete a “header” which reads “FABRICATED REPORT BASED UPON FICTITIOUS INFORMATION.” Margins cannot be more than 1 inch. Reports should range from three to five pages. Please remember that length does not indicate quality. I will be grading based upon you covering all areas in the intake assessment form and using quality sentences.

HERE IS AN EXAMPLE OF HOW IT SHOULD BE DONE DO NOT COPY THIS OR IT WILL BE PLAGIARISM!
There were errors in this example such as, there were some sections missing like childhood, suicide/homicide but this is just an example use the book as a guide for a error free paper, make it sound very real.

FABRICATED REPORT BASED UPON FICTITIOUS INFORMATION

Client Name John Jones Agency# 8009902019

D.O.B. 10/02/2010 Date of Assessment 11/08/2019

PRESENTING PROBLEM

John is described as nine-year-old male who has a passion for exploring and learning. His grandparents who have custody of him are concerned about his incline to act aggressively. He tends to bite and hit others repeatably at school. John is nonverbal and shows his emotions by acting out and playing alone most of the time. He is also unable to play imaginatively or make social connections with other classmates. Upon coming to Wildwood, John was diagnosed with having ASD (Autism spectrum disorder). John has encountered physical and emotionally abuse from his father and was then taken away from him and custody was granted to the grandparents.

As of September 10, 2019, the client was enrolled into the center “Colorful Minds”, in Gulfport, Ms.. Their services will help to create a path for John based upon his behavior analysis and his treatments. The center can be reached Monday through Friday at 228-313-3100. The assessment of life circumstances or changes, will help to provide the grandparents with becoming more knowledgeable of the disease ASD, so the family can work as a whole to resolve Johns aggressiveness. John and his family will also receive social support through interventions and learn the basic principles to improve his social behaviors.

CURRENT MEDICAL CONDITIONS

Through a comprehensive evaluation and an observational assessment, John has been

diagnosed with ASD (Autism spectrum disorder) by his physician, Timothy Bruni. John has been prescribed to take both Risperdal 10mg. and Aripiprazole 15mg. a day, until further notice.

RELATIONSHIP RISK FACTORS

The client is safe living in his grandparents’ home. The client does not seem to feel threatened in any way around his grandparents, However, if his biological father comes around John shows signs of being intimidated, shy, or even hiding from him. Upon hearing additional information from the grandparents, John was abuse physically and emotionally from his father over the last few years after his father went through a bitter divorce and took a lot of the anger out on John. The ongoing evaluations show that John has no signs of being at suicide risk at this time. However, the evaluation of violence is clear that John needs help right away because his actions are significant and destructive when playing with others.

MENTAL STATUS EXAM

I met with John in my office at Wildwood last week, and Johns appearance was well groomed. I was a little surprised, but I was also informed that John is OCD and cares about his appearance a lot. Upon meeting with him his behavior was good in my office. He did not talk but sat very still with his hands on his lap and he made very little eye contact. His mannerism was appropriate for being a non-verbal child. I believe his mood was restricted as he would have like to of been doing other things than sitting in my office. John seems to be slightly anxious as I watched his leg swinging back and forth the entire time as I talked with him and his grandparents. It has been described that John has poor sleeping habits but has a great big appetite that has increased his weight gain.

Johns thought process would be described best as illogical. John tends to act out and misbehave for no reason or explanation. Although, John is not verbal he has a flight of ideas moving from subject to subject all day long. Children who are autistic often have a different thought content. In Johns case, he suffers from what would be logical plan or a well-organized plan. John can be given a task and halfway through and forget the rest of the task. He cannot remember the order of sequences and often gets irritated and shows his behavioral side by throwing items and hitting others when fustrasted.

CLIENT REQUEST, GOALS, EXPECTATIONS

The grandparents are requesting additional information on how to help their grandson relate to his everyday challenges. Simple charts can keep a child on track, or they can be helpful in assisting a child to remember the task and finishing it. The goal and expectations will be that the family will work together as a whole, making the appropriate adjustments in the home to better accommodate for their grandsons needs, and eliminating the “melt-downs” that he has.

CLINICAL SUMMARY

John became the victim after his parents had a bitter divorce. John also has suffered many years of physically and emotional abuse by his father. The abuse over the years has triggered flashbacks, not communicating with others because there has been no trust and acting aggressively towards others. It is my assumption is that the exposure to childhood abuse has elevated John to withdraw and become aggressive by watching his parent fight over the years. My recommendations would be that John remains living with his grandparents and continues to get help and support at Colorful Minds, by interacting with the registered behavioral technicians and going to interventions with his family.

The DSM five diagnostic impression is as follows: (1) Child has diminished interest in playing and doing activities with friends and around the home. (2) Child has had an increase in weight gain due to psychological factors from his past. (3) Child feels guilt, worthlessness and guilt, from a lack of being loved and accepted. (4) The child is deficient in understanding simple task, withdrawing from social interactions and developing through imaginative play. (5) Child is deficient in keeping eye contact and nonverbal communications, which has now led to the symptoms of a child suffering with an autism spectrum disorder.

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