Clients name ___________________________________________________________DOB__________
Age_____Gender______ With what Race/Ethnicity do you most closely identify_____________ ______
I. Family of Origin
A. Where were you born/raised? _________________________________________ ___________
B. Do you have any siblings? Y_____ N _____
Sibling(s)’ names and ages:
What is the birth order of the client? (oldest, middle, etc.) ____________________________ ____
What was it like to be in that position in the family?
C. Are your parents still alive? Y____ N____
Have they ever been married? Y____ N____
Are your parents still married? Y____ N____
Divorces/separations/step-parents? Y ____ N ____
What are your living arrangements? ________________
Parents’ nationality: Mother _________________
Is English her primary language? Y____ N____
Father __________________
Is English his primary language? Y____ N____
Parents’ occupation: Mother __________________
Father __________________
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INTAKE INTERVIEW FORM
(page 2)
D. Family Mental Health History:
Anyone have history of drug abuse? Y ___ N ___
Who?
Alcohol addiction? Y ___ N ___
Who?
Mental illness, emotional disorders (depression, anxiety, schizophrenia)?
Who?
Learning disabilities (mental retardation, literacy deficits, hyperactivity) ?
Who?
E. Have you ever been involved with the legal history? _________ If so, please explain. __________
______________________________________________________________________________
F. Concerns re: family of origin _______________________________________________________
______________________________________________________________________________
II. Occupation/Education:
Highest level of education achieved? ___________________________________________________
How well do you read and write? _______________________________________________________
Where do you go to school? _________________________________________________________
Any special education programs? Y ___ N ___
Explain:
What type of student are you? ________________________________________________________
What are your likes/dislikes about school? _______________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Current job? _______________________________________________________________________
Past employment positions (most recent to past):
Any job-related disabilities? Y ___ N ___
Explain:
Concerns re: school/education
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INTAKE INTERVIEW FORM
(page 3)
III. Medical/Health History
Are you under a doctor's care? Y ____ N ____
Dr.'s name/phone number ___________________________________________________ _____
___________________________________________
Do you have any allergies? N_____ Y_____, list ________________________________________
Are you currently taking any prescribed medication? Y ____ N ____
Type of medication (s) ________________________________________________ ____________
___________________________________________
Other than antibiotics, have you been on prescription medication in the past? Y____ N____
List: ____________________________________________________________________________
Do you have any major health related concerns? Y ____ N ____
List: ____________________________________________________________________________
Does your family have a history of health related concerns? Y ____ N ____
Do you smoke cigarettes? Y ____ N ____ How many? _____________
Do you ingest caffeine? Y ____ N ____ How much? _____________
Do you drink alcohol? Y ____ N ____ How much? _____________
Do you ingest non-prescription drugs? Y ____ N ____
What types? _______________________________________________________ ____________
Concerns re: medical/health status: __________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Any past trauma/abuse?___________________ ________________________________________
____________________________________________________
_________________________________________________
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INTAKE INTERVIEW FORM (for Parents to fill out)
Please check present symptoms:
Always Sometimes Never
Complains of aches and pains
Spends more time alone
Tires easily, little energy, sleeps a lot
Has trouble with teacher/boss
Less interested in school/work
Acts as if driven by a motor (hyperactive)
Impulsive, acts without thinking
Distracted easily
Afraid of new situations
Feels sad, unhappy
Is irritable, angry
Feels hopeless
Has trouble concentrating
Less interested in friends
Fights with others
Hurts others intentionally
Abusive to animals
Cannot be trusted alone
Lies frequently
Inappropriate sexual behavior
Hurts self on purpose
Steals
Is shy
Absent from school/work
School/work performance dropping
Is down on her/himself
Has trouble sleeping
Eats poorly or history of eating disorders
Worries a lot
Wants to be with you more than before
Feels he or she is bad
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INTAKE INTERVIEW FORM
(page 4)
Always Sometimes Never
Takes unnecessary risks
Gets hurt frequently
Seems to be having less fun
Acts younger than other his/her age
Does not listen to rules
Does not show feelings/emotions
Does not understand others feelings
Teases or is verbally abusive to others
Blames others for troubles
Voices from nowhere
Recent weight loss or gain and amount_______
Recent illness, virus or injury
Irrational fears
Has slowed or racing thoughts
Disoriented
Worries about things
Labile (frequent mood swings)
Has difficulty making decisions
Feels guilty
Has crying spells
Has unusual thoughts
Has irrational fears
Is tense
Has memory problems
Panics over things
Compulsive
Others: (list)
Are you suicidal or thinking of hurting yourself? ________________ Or someone else ? _____________
Do you commit to talking to your counselor first should you feel seriously suicidal? ___________________
Date (s) and place (s) of previous out-patient counseling _______________________________________
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INTAKE INTERVIEW FORM
(page 5)
Date (s) and place (s) of previous psychiatric treatment/hospitalization ____________________________
____________________________________________________________________________________
Date (s) and place (s) of chemical dependency treatment ______________________________________
____________________________________________________________________________________
Have you ever attended AA or anything similar? _____________________________________________
Have you ever attempted suicide or tried to harm yourself? (when and how) ________________________
____________________________________________________________________________________
Have you ever attempted to harm someone else? (when and how) _______________________________
Have you ever taken a psychological test? (when and where) ___________________________________
IV. Social/Leisure Activities:
List your preferred leisure activities (hobbies, groups/organizations pastimes).
_______________________________________________________________________________
_______________________________________________________________________________
How many close friendships have you established? ______________________________________
How often do you engage in social activities? ___________________________________________
How often do you engage in family activities? With whom? ________________________________
_______________________________________________________________________________
Concerns re: social/leisure activity ____________________________________________________
_______________________________________________________________________________
V. AAT (Animal-Assisted Therapy) Experiences:
Animal experiences _______________________________________________________________
Have you ever had a pet? ______________________________________________________
What happened to it?__________________________________________________________
Any AAT previously? ______________________________________________________________
Concerns re: animals, fears, environment, etc? __________________________________________
VI. Religious Background:
Do you have a preferred denomination? __Y __N
Which ? ________________________________________________________________________
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INTAKE INTERVIEW FORM
(page 6)
What is/was your family's primary denomination? ________________________________________
Are you currently active in a church? __Y __N
Describe ________________________________________________________________________
Concerns re: religion/spiritual ________________________________________________________
VII. Goals:
What do you want from your counselor in your therapy experience? _________________________
_______________________________________________________________________________
What do you want to change in your own behavior or attitude? ______________________________
_______________________________________________________________________________
Or in your situation? _______________________________________________________________
_______________________________________________________________________________
Do you believe you need medication? Yes ____ No ____
Are you open to medication? Yes ____ No ____
Do you believe you need hospitalization? Yes ____ No ____ Why? _______________________
_______________________________________________________________________________
_______________________________________________________________________________
Is your parent or family member willing to come in if necessary? Yes _____ No _____
Are they willing to support your changes in other ways? (verbally, reading, etc.) Yes_____ No_____
Please list the exact transformation goals you have for therapy:
___________________________________________ _______________________
Client's signature Date