To be completed by EAP Counselor  
EAP Policy: Out of Town  
EMPLOYEE ASSISTANCE PROGRAM INTAKE ASSESSMENT
Client Name            Date    
Employer             
Presenting Problem:
  Client Alcohol/ Drug   Family Alcohol/ Drug   Relationship   Abuse
  Emotional   Work Performance
Marital
Sexual
  Job Related Stress   Psychological
Significant Other
Physical
  Legal   Career
Parent/ Child
Mental
  Financial   Elder Care
Work
Substance
  Medical   Other  __________________________________________________
Assesed Problems
  Client Alcohol/ Drug   Family Alcohol/ Drug   Relationship   Abuse
  Emotional   Work Performance
Marital
Sexual
  Job Related Stress   Psychological
Significant Other
Physical
  Legal   Career
Parent/ Child
Mental
  Financial   Elder Care
Work
Substance
  Medical   Other  __________________________________________________
Mental Status
Appearance: Attitude: Motor Activity Speech
  Well Groomed       Cooperative   Calm   Pressured
       
  Bizarre      Suspicious   Agitated   Perservating
       
  Dishevelled     Beligerant   Muscle Spasms   Incoherant
     
  Inappropriate   Guarded   Hyperactive   WNL
   
  WNL   Uncooperative   Tremors/Tics
 
  Psychomotor Retardation
Mood  Affect Anxiety Depression
  Normal   Appropriate   Racing Thoughts   Mild
   
  Anxious   Expansive   Obsessive   Moderate
   
  Angry   Blunted   Compulsions   Severe
   
  Depressed   Worrisome   Panic Attacks   Psychotic Features
   
  Euphoric   Apathetic   GAD   Suicidal
   
  Loud   Labile   WNL   NA
   
  Excessive   Constricted
   
  Flat
 
  Sad
Cognitive Function Orientation Memory
  Intact   Fully Orientated   Intact
     
  Impaired   Disoriented - Place   Impairment - Recent
   
  ADHD   Disoriented - Situation   Impairment - Immediate
   
  ADD   Disoriented - Time   Impairment - Remote
 
  Paranoia   Disoriented - Person
 
  WNL   Somewhat Impaired
Stuecker & Associates Fax: (502) 452-1529 Phone: (800) 799-9327
EMPLOYEE ASSISTANCE PROGRAM INTAKE ASSESSMENT (page 2)
Judgement Insight Self Perception
  Intact   Intact   No Impairment
     
  Impaired   Impaired   Derealization
  Depersonalization
MEDIAL/PSYCHIATRIC HISTORY
Medical History:                      
             Medication                      
Psychiatric History:                      
             Medication                      
Drug/Alcohol History:
  No   Yes                
Substance Abuse Assessment:
  No   Yes                
SASSI given?   Yes   No
Family Alcohol/Drug History:
  No   Yes                
Work History/Performance Issues:
  No   Yes                
Financial/Legal:
  No   Yes                
History of Abuse:
  No   Yes     If yes, use Abuse questionaire
                           
Suicidal Risk Assesment:  
  Ideation   No   Yes  
   
  Plan   No   Yes  
                           
Assessment/Intervention Plan:                    
                           
             
Treatment Goals:                    
                           
             
Does this person need to be referred for long-term treatment?
  No   Yes              
Referral Source:
Name(s):          
Phone:           Accepted:   Yes   No   
Notes:                          
                           
                           
Counselor's Signature            
Stueker & Associates Fax: (502) 452-1529 Phone: (800) 799-9327