Psychological Assessment Intake Intervie

INTAKE INTERVIEW
Date: By:
I. DEMOGRAPHIC INFORMATION
Name:
Date of Birth: Age: Sex: Male ( ) Female ( )
Marital Status: Single ( ) Married ( )
Partnered ( ) Separated ( )
Divorced ( ) Widowed ( )
Complete address:
Phone:
Mobile:
E-mail address:
Highest Educational Attainment:
Occupation:
Company:
Position:
Company address:
Reffered by:
Reason for Referral:
II. PROBLEM ANALYSIS

PROBLEM DESCRIPTION: What are your main concerns? What is it that made you decide to seek the help of a
psychotherapist? Could you describe the problem/s you wish you had the most help with right now?
INITIAL ONSET: When did the difficulty first begin?
FREQUENCY: How often does it occur? Have there been any changes in how often it has occured?
ANTECEDENTS/CONSEQUENCES: What usually happens before the difficulty/problem present itself? In what context or
situation does it usually occur? What happens after the behaviour/s occur/s?
PROBLEM INTENSITY: How would you rate the intensity of the problem or concern that you brought in?
1 2 3 4 5
NO INTENSE EXTREMELY INTENSE
PROBLEM DURATION: Approximately how long have you had the current problem?
EFFECTS: In what ways has this problem affected you?
COPING ATTEMPTS: In what ways have you attempted to cope with this problem?
PREVIOUS TREATMENT/FORMAL TREATMENT: Is this the first time that you have considered the help of a mental health
professional? If not, then whom did you seek previous treatment from? What was the outcome?
III. FAMILY BACKGROUND

1. Tell me about your family of origin. Kindly, describe each family member in terms of their personalities, intelligence, the role
each person played in your upbringing as well as your current relationship with each of them.
2, What do your parents do for a living? Can you describe their lifestyle? What kind of activities do they engage in?
3. Could you describe to me the neighbourhood where you grew up? Hoe about your home environment? Give me a good
picture of the various households in which you have lived.
4. Are your parents still married or are they separated? Could you describe their relationship to each other?
5. How would you describe the way your parents brought you up? Were they particularly strict, punitive, or tolerant of your
behavior? How would you describe their parenting style?
6. How would you describe your relationship with your mother?
7. How would you describe your relationship with your father?
8. Whom were you particularly close?
9. Whom did you have the most conflicts with?
10. Tell more about your siblings.
11. Do you know of any major medical or psychological problem/s in any of your family members? What is your parent’s
current state or health and well-being?
12. Who in your family do you currently feel closest with? Most distant with? In most conflict with?
13. With regards to your current difficulties, do you think your family members are supportive, indifferent, or destructive?
14. How is your family a source of emotional support for you?

( ) none ( ) little ( ) somewhat ( ) substanial ( ) very strong
IV. PERSONAL HISTORY

1. Can you recall descriptions or stories about you as a baby? Did your parents mention signs of behaviour problems during
your early childhood? What was your temperament and personality as a child?
2. Did you have friends in school? Kindly describe to me your social relationships during this time.
3. Can you tell me about your peer relationships during from prepuberty through adolescence? Do you have many friends
during this time and how close were you to them?
4. Were you popular in school? Did you belong to a particular group/clique? Describe this group that you belong in. Did you
participate in group or gang activities?
5. Did you have role models this time? Were there people you idealized or idolized?
6. Did you have a particular emotional or physical problem when you were an adolescent?
V. EDUCATIONAL BACKGROUND
1. What schools did you go to?
2. Did you encounter any problems, whether academic or relational, when you were a student? How did you perform in school?
3. What were your other interests when you were a student? Did you engage in sports or were there advocacies that you were
particularly active in during this time?
4. How would you describe your relationship with your classmates? Teachers?
5. Did you have any difficulty in any of your school subjects? In terms of academic achievement, in which areas did you excel
as a student?
VI. SEXUAL DEVELOPMENT

1. Would you describe to me your earliest curiosities regarding sex?
2. What were your feelings regarding sex when you were in your puberty?
3. When did you first have your menstruation and what did you feel about it?
4. Let's talk about your attraction to people. Are you attracted to the opposite sex, to the same sex or both?
5. Did you go on dates?
6. What was your recollection of having your first crush in school or in your neighbourhood?
7. Have you ever engaged in any form of sexual activity in the past? How did you feel about it?
VII. ADULTHOOD
1. Can you describe your religious background? What are your current religious practice?
2. Is spirituality important in your life? How do you express your faith and spirituality?
3. Can you tell me something about the different jobs held in the past?
4. What is your relationship with authority, peers,and subordinates at work?
5. How many jobs did you have in the past and what were their durations?
6. What is your current job and how do you feel about it?
7. Do you have friends?
8. What are your social, intellectual and physical interests?
9. Can you describe to me your romantic and/or sexual relationship with the same or opposite sex?
10. Can you tell me something about the depth, duration and quality of relationships you have with important people in your life
right now?
11. What are you career ambitions?
12. Are you married? Can you tell me more about your spouse? Describe your relationship with your partner. What are the
areas of aggreement and disagreement between you and your partner?
13. What are you attitudes towards raising children?
14. Do you experience problems with any of your family members?
15. What is the role of in-laws in your life?
16. What are your attitudes toward pregnancy and having children? How about contraceptives?
17. Do you have any particular sexual practice that you consider unique or unusual?

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INTAKE INTERVIEW

Highest Educational Attainment:

II. PROBLEM ANALYSIS

INITIAL ONSET: When did the difficulty first begin?

EFFECTS: In what ways has this problem affected you?

III. FAMILY BACKGROUND

7. How would you describe your relationship with your father?

8. Whom were you particularly close?

9. Whom did you have the most conflicts with?

10. Tell more about your siblings.

14. How is your family a source of emotional support for you?

IV. PERSONAL HISTORY

VI. SEXUAL DEVELOPMENT

5. Did you go on dates?

4. What is your relationship with authority, peers,and subordinates at work?

7. Do you have friends?

8. What are your social, intellectual and physical interests?

11. What are you career ambitions?

13. What are you attitudes towards raising children?

14. Do you experience problems with any of your family members?

15. What is the role of in-laws in your life?

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