INTAKE ASSESSMENT

Intake Interviewer: Flory Ann Evia

Client Name: Edgar Cheverez III
PRESENTING PROBLEM
Identifying Information:
Gender: Male
DOB: 3/13/2003
Age: 12
School (if applicable): Patrick Henry Elementary
Relationship status: Single

Race: Filipino/Puerto Rican

Work (if applicable): n/a

Presenting Problem: The intake took place in one brief session where Edgars mother was in a rush to
complete the session. Edgars grandma made the decision for his mother to bring him for counseling due
to his inability to enjoy activities, impulsivity, and lack of empathy. Grandma would report how he would
have difficulty in continuing a conversation and start hand flapping. Mother also mentions how he is very
unsocial and he would not establish friendships in school. Mother states that he is an only child.
History of Presenting Problem and Treatment: Edgars mother mentions how it was difficult to raise
Edgar and had to switch schools three times. He had a delay in learning to talk between the ages of
three-years-old to ten-years-old. Grandma would also take care of Edgar while mother is at work and
grandma would show concern towards Edgar not understanding her perspective or feelings. Edgar would
always try to wander off or becomes abruptly hyperactive. Mother felt that it was Edgar going through
stereotypical teenage years and denied previous counseling but realized his actions became worse.
Family History and Relationships (including family mental health history): Edgar lives in an
apartment with his mother on the north side of Chicago. The mother and father went through divorce
when Edgar turned five-years-old. Edgars mother has legal custody and his father is barely around.
Edgars mother reports how Edgar would sometimes ask for his father and it would be a difficult time
because he does not understand the divorce. This is Edgars first encounter with counseling and his
mother has been concerned about his behavior since he was three-years-old. Mother admits to her
smoking cigarettes problem and does not smoke around Edgar. It is unknown if father is alcoholic or
drugs. Edgars father is currently serving US Marines and experiencing post-traumatic stress disorder.
This information may be old due to the mother and father barely communicating.
HISTORY/MEDICAL
History of Sexual or Physical Abuse/Trauma: Edgar and his mother denied any history of sexual or
physical abuse or trauma.
Medical and Health History: Mother reports client is in good health and has no remarkable medical or
health history.
Daily Living Skills: Mother states how Edgar must sleep before 9pm because he will become cranky.
Edgar acts accordingly but his mother would have to repeat her sentences to him. Mother mentions how
Edgar seems to have had delayed in reaching certain appropriate developmental milestones. There was
no smell of smoke on their clothing and Edgar dressed properly but exhibited random behavior for short
periods of time such as hand flapping, focusing on one object, mumble gibberish, etc.
Substance Use/Abuse/Dependence: Cooper denied that he has any current of past alcohol, tobacco, or
other drug use. Mother admits to smoking privately due to stressful life events. Mother does her best to
prevent second hand smoke as well as third hand smoke and is very clean around her son.
INTERESTS/STRENGTHS

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Cultural/Ethnic/Religious Identification: The father is Puerto Rican descent and the mother is Filipino
descent. The family, without father, attend a Catholic church and engage in Saturday religious
educational classes. Edgar shows no interest in this program.
Interests, Activities, and Hobbies: Edgar enjoys watching movies and playing video games. He loves
Toys Story and Mario Bros games which he has on his Xbox, Wii, and Nintendo 3DS. He claims to be
interested in sports but would rather play on his Nintendo 3DS. He loves playing the piano and is currently
taking piano lessons.
Client Strengths and Resources: Mother states that Edgar is funny and talented when he wants to be
but can be very emotionless at times. Edgar reports that he loves playing piano and looks forward to
performing at the annual recital.
Client/Guardian willingness and ability to participate: Edgar and his mother both reported being
willing and able to participate in treatment. Edgars grandma is also concerned and would be willing to
participate in treatment as well.
DIAGNOSES
Current Diagnoses:
Autism
Attention Deficit Hyperactivity Disorder
SUMMARY
Summary and Conclusions: Edgar is a twelve-year-old Puerto Rican mixed with Filipino male who has
a history of disruptive behavioral problems associated with attention problems, lack of empathy, and
impulsivity. He lacks a father figure in his upbringing and this can contribute to his behavior problems.
Edgars mother is very concerned with his mind and how he will grow up to adapt to social norms.
Edgars behavior at this point merits a diagnosis of Autism or ADHD.

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