A.

CLIENT INFORMATION
Name: Interview Date (DD/MM/YYYY):
Age: Date of Birth (DD/MM/YYYY):

Sex: Gender: Sexual Orientation:

 Female  Female  Straight/heterosexual
o Male o Male  Bisexual
o Lesbian/gay/homosexual
 Asexual
 Unsure/questioning
 Transgender
 Prefer not to answer
o Other: _______________
Marital Status: Parental Status (No. of Current Education Level:
children):
Religion: Racial/Ethnicity:

Languages: Primary Language:

Reasons for Referral:

B. PRESENTING PROBLEM
Main concern, onset (when did it first begin), frequency, severity (1-10), duration, course
(how long), triggers), action taken/help-seeking, coping strategies, sleep and appetite,
somatic concerns (physical symptoms), why now? What might have contributed to the
problem(s)?
B. Main Concerns and History of Presenting Issues:
C. FAMILY BACKGROUND AND HISTORY
How many people, living situation (all stay together?), demographic info (age, occupation,
divorce/marriage status, death, etc.), if have children, how many children? mental &
physical health history, major life events (migration, trauma, etc.)
i. Family Genogram

Relationships, roles (decision-maker, caretaker, etc.), communication styles, any of them

know your problem(s)
ii. Family Dynamics

Parents’ approach to discipline, rules and expectation, freedom of opinions expression

iii. Parenting Styles:
D. DEVELOPMENTAL HISTORY
Circumstances surrounding conception, any complication, mother’s pregnancy normal?
D. Developmental History

E. EDUCATION HISTORY
School name(s), academic performance (primary to current), school environment &
experience, relationships (teachers & friends), challenges, significant events
i. School and Achievement

Favorite subjects/topics, extracurricular activities, hobby

ii. Interests and Play

F. SOCIAL HISTORY
Any close friends, how many friends (if foreigner, nationalities of friends), relationships
with them, contact frequency, social confidence (comfortable in social settings),
romantic/sexual relationship, anyone knows your problem? What is their responses?
i. Social Interactions

Typical daily schedule, leisure activities, sleep patterns (when go to bed/wake up), stress
handling mechanisms
ii. Daily Routines
G. PERSONAL STRENGTHS AND TRAITS
Personal strengths, frequently think about future?
G. Personal Strengths and Traits

H. OCCUPATIONAL HISTORY
Present job, past job, reason for job changes, working environment, relationships with
colleagues, financial situation
H. Occupational History

I. MEDICAL, PSYCHIATRY & PSYCHOLOGICAL HISTORY

Any medical history/issues/surgeries, hospitalized history, psychiatric histories, any
disabilities, hallucination check, delusional thinking, derealization/depersonalization check
I. Medical, Psychiatry & Psychological History
J. SUBSTANCE USE/PROBLEM HABITS
Alcohol/substance/drug/smoking consumption history, frequency, problem created
Internet addiction, other addictions
Prescription Medication
J. Substance Use and Problem Habits

K. CULTURE/ETHNICITY AND SPIRITUALITY/RELIGION

Culture/Ethnicity (identification, any issues), Spirituality/Religion (level of importance,
practice), family share the same practice? If no, where they get the belief system? Helpful
for the problem faced?
K. Culture/Ethnicity and Spirituality/Religion

L. LEGAL HISTORY
Involved in any active legal cases (traffic, civil, criminal)
L. Legal History

M. HISTORY OF ABUSE
Sexual abuse, physical abuse, emotional abuse, who (family, etc.)
M. History of Abuse

N. RISK OF HARM ASSESSMENT

N. Risk of Harm Assessment
Self-Harm

Suicide

O. CLIENT GOALS AND EXPECTATIONS

Goal(s) and how to know if there is improvement
O. Goals and Expectations

P. BEHAVIORAL OBSERVATION
Domain Subdomain Description Comments
Appearance Posture Normal
and Behavior Limp
Rigid
At ease
Gesture Normal
Agitated
Tics
Twitches
Grooming Neat
Well groomed
Disheveled
Meticulous
Dress Appropriate
Casual
Formal
Dirty
Careless
Inappropriate
 Seductive
Facial Expression Appropriate
Poor eye contact
Dazed
Staring
Speech Pace Normal
Retarded
Pressured
Blocking
Speech Volume Normal
Soft
Very loud
Monotone
Speech Form Logical
Illogical
Rambling
Rational
Incoherent
Coherent
Speech Clarity Normal
Garbled
Slurred
Speech Content Normal
Loose
Associations
Rhyming
Obscene
Attention/ Attention Normal
Affect/ Mood Short span
Hyper
Alert distractible
Mood Normal
Elated
Euphoric
Agitated
Fearful
Hostile
Sad
Affect Inappropriate
Shallow
Flat
Intense
Perceptionand Hallucination Auditory
Thought Visual
Content Tactile
Gustatory
Olfactory
 Delusions Paranoid
Grandiose
Control
Insertion
Thought withdrawal
Illusions Visual
Auditory
Other Phobias
Derealization Obsessions
Compulsions
Ruminations
Suicide/homicide Ideation (plans)
Orientation Time
(for Place
adolescents Person
and adults
only)
Judgment Intact
Impaired
Concentration Memory Intact
and Memory Impaired
Immediate recall Good
Poor
Reversals Good
Poor
Concentration Good
Poor

Abstract Similarities Good

Ability Poor
Bizarre
Absurdities Recognized
Not recognized
Proverbs Appropriate
Literal
Concrete
Bizarre
Insight Good
Fair
Poor
Absent