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basic format of intake interview

The document outlines a Basic Intake Interview Format for counselors to gather essential information about clients. It includes sections for personal and family information, presenting problems, mental health history, family history of mental illness, mental status examination, current symptoms, coping mechanisms, client expectations, and counselor observations. This structured format aims to facilitate a comprehensive understanding of the client's situation and needs.

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tanikachib90
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7 views

basic format of intake interview

The document outlines a Basic Intake Interview Format for counselors to gather essential information about clients. It includes sections for personal and family information, presenting problems, mental health history, family history of mental illness, mental status examination, current symptoms, coping mechanisms, client expectations, and counselor observations. This structured format aims to facilitate a comprehensive understanding of the client's situation and needs.

Uploaded by

tanikachib90
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Basic Intake Interview Format

Basic Details
• Date of Interview: __________________________

• Counsellor Name: __________________________

• Client Name: __________________________

• Age: __________

• Gender: __________

• Marital Status: __________________________

• Occupation/Student (If applicable): __________________________


• Referral Source: _____________________

1: Personal and Family Information


1. Family Composition:

o Number of family members: __________

o Relationship with each family member:

2. Family Dynamics:

o Any history of conflict or dysfunctionality:

3. Support System:

o Whom does the client rely on for emotional support?

4. Sociocultural Background:

o Religion/Cultural influences, if relevant:


2: Presenting Problem
1. Reason for Seeking Help:

2. Onset and Duration:

3. Impact on Daily Life:

3: Past Mental Health and Medical History


1. Past Mental Health History:

2. Medical History:

3. Substance Use (If Any):

o Alcohol/Drug use: Yes [ ] No [ ]

o Details (if applicable):

4: Family History of Mental Illness


1. Any history of mental illness in the family:

o Yes [ ] No [ ]
o Details:
5: Mental Status Examination (MSE)
1. Appearance and Behavior:

2. Speech:

3. Mood and Affect:

4. Thought Process and Content:

5. Perception:

6. Cognition:

7. Insight and Judgment:

6: Current Symptoms
1. Emotional Symptoms:

2. Behavioral Symptoms:

3. Physical Symptoms:
7: Coping Mechanisms and Strengths
1. Current Coping Mechanisms:

2. Personal Strengths:

Section 8: Client’s Expectations

1. Client’s Goals for Counseling:

2. Immediate Concerns or Requests:

9: Summary and Counsellor’s Observations


1. Summary of Findings:

2. Counsellor’s Impressions:

3. Plan/Next Steps:

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