Sarai Espinoza Ruiz 160036

INTAKE REPORT
Name

Age

Marital Status / Family Background.

Sex

Clare

10 years old

Single/ lives with her

mother, only child

Female

Race

Educational Background

Occupation

Date of the

Student/ Mother (stays at

home)

interview

Caucasian

th

4 grade,
elementary
school

09/11/14

I.

Presenting Problem
Clare is brought by her mother, because the girl has been ordered by the
judge to have counseling, since she has been experienced and witnessed
physical and verbal abuse from her father to her mother for the past 2
years. Since she is a minor, the mother had to be interviewed as well.
However when I interviewed Clares mother she said that the girl has not
witnessed anything. She also said that Clares father is not aggressive he
just get angry sometimes. When the mother was asked how did Clare got
an order from the judge to take counseling, she answered that a few days
before, some neighbors called the police because of the yelling that was
going on in her house. When the police officers came, they saw Clare crying
and took the case to the judge. Nevertheless, the mother seems to be in
denial about the issue. She mentioned there is not a problem with Clare and
that she is perfectly fine. She also denied that there is a problem with her
husband, who is actually in jail for his last behavior, and she is waiting for
him to go out of jail, so they can be together again.
On the other hand, when I talked to Clare, she said she usually sees her
parents fighting all the time. She hides in the stairs and witness everything
the father does. Clare expressed that her father is not very nice and that
she is scared of him. When I asked her about her fathers behavior, she
described his behavior as aggressive and rude; she mentioned that her
father yells at her and her mom, he drinks, and sometimes he pushes her
when she doesnt listen. He also throws things to her mother and she
remember one time, when she was 8 years old, that her mom had to go to
the hospital because her father had thrown a chair to her and she got hurt.
Clare also refer that she has been wetting the bed again (something that her
mother didnt mention) and she doesnt want to be with her dad, it makes
her sad the fact to see her mother crying all the time and watching her
cleaning up the mess that her dad does after he yells.

II.

Family History
Clares parents have been together for the past 10 years, in which 8 of them
were just living together and the last 3 years have been married. Clare is the
only child of the family and she doesnt have any relative close to her.
The relationship with her mother is described as a good relationship.
Although Clare keeps secrets to her mother, because she doesnt want her
to know that she knows about the fighting. Also Clare doesnt talk to her that
often, even when the mother is in the house all the time, she seems to be
absent almost all the time. Conversely, Clares mother expressed that her
relationship with her daughter is very close.

Moreover, the relationship with her father is very distant; she rarely talks to
him and she is very afraid of him as well.
III.

Medical History
There is not any relevant medical record from Clare; She has not got any
hospitalization, surgery whatsoever. Her mother on the other hand, has
been in hospitalization before, because her father hurt her.

IV.

Relationship History / Educational History

Clare is coursing 4th grade in elementary school, she said she likes the
classes, even when she is not that good in math. However, since school is
the main place where Clares interpersonal relationships take place, it is
important to know her relationships in school. Clare expressed that she
doesnt have any friend at school; she thinks that no one likes her, because
nobody talks to her. Outside the school, she doesnt have any friends
neither. She also mentioned that her mom doesnt have friends and she
doesnt talk to anyone.

V.

Mental Status
Clare is 10 years old; her mental age is the same as her chronological age.
She is located in time and space. She is tall, blond hair, and blue eyes. She
was presented to the office with a purple shirt and blue jeans. She was well
groomed and with good hygiene.
At the beginning of the consultation, she was anxious; moving her feet often
and fidgeting, her facial expression showed nervousness. As the
consultation progressed she showed more relax, with good disposition and
willing to answer the questions. Her attention was good, not easily
distracted. Her language was understandable, normal speed and moderate
voice. Her conversation was coherent and fluid.

VI.

Diagnostic Impressions
My prior diagnostic for Clare is Domestic Violence; and that has been
causing almost all Clares issues such as lack of relationships, withdrawal
behavior, regression in some areas, low self-esteem, and anxiety (for being
living with fear for the last 2 years). Besides, there is not a good family
support with her, which make things even harder for her.
It is important to highlight that Clare has been manipulated by her mother.
Since she tells her that she shouldnt talk to anyone about their problem
because there is not such thing. It seems like Clares mom wants to keep
that as a secret so she can stay with her husband, which puts Clare in a
very dangerous place. I also noticed that the mother is very concerned
about what I can say to the judge, so she appears to be nice and kind
although she wants to be in control on the situation, and also wants to know
what Clare is saying to others.

VII.

Therapeutic plan
I think it is important to work with Clares mother as much as with her;
because the mother is in total denial of the situation, she is in the cycle of
violence and not willing to leave her husband. Therefore I believe, it is

crucial to work with the mother if I want to see an advance with Clare, and
look for Clares safety.
VIII.

Therapists Signature: Sarai Espinoza Ruiz

My reaction on doing the Intake Report

In doing my intake report, I felt all right and excited, since the interview with
the patient is one of the things I like the most.
I think the first interview is very important and will give rise to have either
good or bad relationship with the patient during the remaining sessions.
Hence the intake report is also something very important because it will
guide the following sessions; it serves in giving us an accurate description
and summary of the situation and the context of the patient.
Likewise it helps to organize the information we are receiving as well as get
to know the specific areas that are more damaged than others and how we
can link them for best results.
Thats why I believe the intake report is an important and very useful piece in
the therapy.