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Intake Interview Form Template

The document is an intake interview form designed for professional use, collecting confidential client information such as personal details, presenting problems, and mental status. It includes sections for previous treatment, family background, diagnostic impressions, treatment plans, and recommendations. The form requires signatures from both the counselor and a supervisor upon completion.

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bebetocyberk
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130 views3 pages

Intake Interview Form Template

The document is an intake interview form designed for professional use, collecting confidential client information such as personal details, presenting problems, and mental status. It includes sections for previous treatment, family background, diagnostic impressions, treatment plans, and recommendations. The form requires signatures from both the counselor and a supervisor upon completion.

Uploaded by

bebetocyberk
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

INTAKE INTERVIEW FORM

CONFIDENTIAL: FOR PROFESSIONAL USE ONLY

Intake Interview
Intake Counselor: _____________________________________________________
Client Name: _____________________________________________ Date of Intake: ________________

Date of Birth: _______________________________ Occupation: _______________________________


Age: _______________________________ Residence: _______________________________
Gender: _______________________________ Marital Status: _______________________________
Nationality: _______________________________ Contacts (Mobile):_____________________________
Religion: _______________________________
_______________________________________________________________________________________________

Next of Kin: ___________________________________________________________________


Relation to Next of Kin: ________________________ Next of Kin Contacts: ________________________
_______________________________________________________________________________________________

IDENTIFYING INFORMATION / OBSERVATIONS:

PRESENTING PROBLEM:
INTERVIEW BEHAVIOR:

PREVIOUS TREATMENT INCLUDING COUNSELING:

FAMILY BACKGROUND:

MENTAL STATUS:
Suicidality:
Homicidally:
Hallucinations:
Delusions:
Substance Abuse:
Case Formulation:

DIAGNOSITIC IMPRESSIONS:
Code Diagnosis

TREATMENT PLAN (Includes Goals)

RECOMMENDATIONS:

Signature: Date:
Counselor

Supervisor: Date:

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