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I. Identifying Data: Nature of Problem

This document contains an intake interview form for a psychology course. The form collects identifying information about the client such as name, age, education level, and contact details. It also asks about the reason for referral, presenting concerns, personal and family history, medical history, work, education, religion/spirituality, recreation/interests, and self-description. The purpose is to gather a holistic understanding of the client's background and current issues to inform their counseling.

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Rosa Espiritu
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© Attribution Non-Commercial (BY-NC)
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Download as PDF, TXT or read online on Scribd
104 views

I. Identifying Data: Nature of Problem

This document contains an intake interview form for a psychology course. The form collects identifying information about the client such as name, age, education level, and contact details. It also asks about the reason for referral, presenting concerns, personal and family history, medical history, work, education, religion/spirituality, recreation/interests, and self-description. The purpose is to gather a holistic understanding of the client's background and current issues to inform their counseling.

Uploaded by

Rosa Espiritu
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Intake Interview for PSY660M

Prepared by Rosalind Espiritu

Date: _________________
Time: _________________

I. IDENTIFYING DATA

Name: _________________________________ Education: grade, ___ high ___, college ___, post grad ___
Age: ____ Birthdate: ________________Ethnic Background & Nationality:___________________
Civil status: single ___, married ___, sep _____
Religion: _______________________________________
Occupation: ____________________________ Legal problem: no, yes ____________________________
Contact no. _____________________________ Interviewee: client, ___ parent ___, sibling ___,
guardian ____, teacher ____, others _______
Address: _____________________________________________________________________________________
____________________________________________________________________________________________

II. REASON FOR REFERRAL

Nature of Problem
____ Academic ____ Adjustment _____Personal
____ Family ____ Behavioral _____Others: ________________________

Presenting Concern
Triggers: ____________________________________________________________________________________
Frequency: __________________________________________________________________________________
Severity: ____________________________________________________________________________________
Duration: ____________________________________________________________________________________
Coping: _____________________________________________________________________________________

III. PERSONAL HISTORY

Family Tree (include name, age, grade/level or occupation of family members, closeness of family relationships,
and discipline methods used by parents):
Intake Interview for PSY660M
Prepared by Rosalind Espiritu

Family background:
Living conditions:
Living with: ___________________________________________________________________________
Description of neighborhood: _____________________________________________________________
_____________________________________________________________________________________
Significant family events (migration, separation, adoption, deaths, etc.): __________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Developmental concerns (socio-emotional and cognitive): _____________________________________________


____________________________________________________________________________________________
____________________________________________________________________________________________

Fears: ______________________________________________________________________________________

Strange experiences (disorientation, hallucinations, etc.): ______________________________________________


____________________________________________________________________________________________

Other concerns: _______________________________________________________________________________

Medical History:
Course of pregnancy: __________________________________________________________________________
Circumstances of delivery: _____normal, ______ caesarian
Family members' past illnesses:
____Past Psych consult ____coffee _____tea
____Past Psych hospitalization ____marijuana _____Benzodiazepines
____Past Intake of Psych meds ____Methamphetamine _____cough syrup
____Past suicide attempt ____herbal drinks _____hair dye
____Allergy ____drive _____medical condition
____Past medical hospitalization ____medication intake _____smoking
____Alcohol ____Others: _____________________________
Client's past illnesses:
____Past Psych consult ____coffee _____tea
____Past Psych hospitalization ____marijuana _____Benzodiazepines
____Past Intake of Psych meds ____Methamphetamine _____cough syrup
____Past suicide attempt ____herbal drinks _____hair dye
____Allergy ____drive _____medical condition
____Past medical hospitalization ____medication intake _____smoking
____Alcohol ____Others: _____________________________

Psychosexual development
First menstrual period: _____________________________________________________
First awareness of sexuality: _____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Sexual activities: ______________________________________________________________________________
____________________________________________________________________________________________
Views of sexual expression: _____________________________________________________________________
___________________________________________________________________________________________
Intake Interview for PSY660M
Prepared by Rosalind Espiritu

IV. WORK HISTORY

Date Job description Reason for changing job Perception of working environment

V. EDUCATIONAL HISTORY

Date & Year level Description


Honors & awards
Difficult subjects
Subjects with high grades
Subjects with low/failing grades
Interesting/favorite subjects
Relationship with classmates &
teachers

VI. RELIGION/SPIRITUALITY

Spiritual practices engaged in: ___________________________________________________________________


____________________________________________________________________________________________

Significant spiritual experiences: _________________________________________________________________


____________________________________________________________________________________________
____________________________________________________________________________________________

Perception of own religiosity or spirituality: ________________________________________________________


____________________________________________________________________________________________

VII. RECREATION/INTERESTS

Hobbies & interests: ___________________________________________________________________________


____________________________________________________________________________________________

Views towards hobbies & interests: _______________________________________________________________


____________________________________________________________________________________________

VIII. SELF-DESCRIPTION

Strengths & Weaknesses: _______________________________________________________________________


____________________________________________________________________________________________
Intake Interview for PSY660M
Prepared by Rosalind Espiritu

____________________________________________________________________________________________

Most important decisions & changes in life: ________________________________________________________


____________________________________________________________________________________________
____________________________________________________________________________________________

Plans & dreams for the future:


Five to ten years from now: ______________________________________________________________
_____________________________________________________________________________________
What must be accomplished to make dreams/plans a reality: ____________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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