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Intake Interview Form

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ArleneRamos
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66 views3 pages

Intake Interview Form

Uploaded by

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

Department of Education
Region VI-Western Visayas
SCHOOLS DIVISION OF KABANKALAN CITY
INAPOY NATIONAL HIGH SCHOOL
Inapoy, Kabankalan City

INTAKE INTERVIEW FORM


Name: ______________________________________________________________ Date: __________
Birth Date: __________________ Sex: ________ Preferred Language: ______________________

We are concerned about how things are going for you. Our session today will help us
discuss what’s going O.K and what’s not going so well. Everything is confidential except for
those that need to be discussed with others in order to HELP you.

1. How would you describe your current situation? What problems are you experiencing? What
are your main concerns?
__________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________
2. How serious are these matters for you at this time?
___ Very serious ____ Serious _____ not too serious _____not
serious at all
3. How long have you had these problems?
_____0-3 months _____4 months to a year ____ more than a year
4. What cause these problems?_____________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________
5. Do others (parents, guardian, and friends) think there were other cause? If so, what do they
say? _______________________________________________________________________________________
______________________________________________________________________________________
6. What other things are currently making it hard to deal with the problems?
________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7. What have you already tried order to deal with the problem.
___________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________
8. Why do you think these things didn’t work?
_________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
9. What others advised you to do? __________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________
Address: Inapoy, Kabankalan City
Email: [email protected]
Cp #: 0960-6183620
Republic of the Philippines
Department of Education
Region VI-Western Visayas
SCHOOLS DIVISION OF KABANKALAN CITY
INAPOY NATIONAL HIGH SCHOOL
Inapoy, Kabankalan City

10. What do you think would help to solve the problem?


_________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
11. How much time and effort do you want to put into solving the problems.
____none at all ____only a little _____ just enough ____very much

If you answer 1st, 2nd, or third option, why don’t you want to put more time and effort into
solving the problems.
____________________________________________________________________________
_____________________________________________________________________________________
12. What type of help do you want? _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. What changes are you hoping for? ______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
14. how hopeful are you about solving the problems?
___very hopeful ___hopeful ___ somewhat hopeful ____hopeless

If you are hopeless, why? _______________________________________________________________


_____________________________________________________________________________________
_____________________________________________________________________________________
15. What else should we know so that we can help? Are there any other matters you want to
discuss?
_______________________________________________________________________________________________
_______________________________________________________________________________

For Interviewer/ counselor only: Do not write anything below the line
========================================================
==
Name of Interviewer/ Counselor: _____________________________________________ Date:__________
Note the identified problem: ________________________________________________________________
_______________________________________________________________________________________
Is the counselee seeking help? ________ yes ____________ no
If not, what are the circumstances that brought the counselee to the interview?
______________________
_______________________________________________________________________________________________
______________________________________________________________________________
Address: Inapoy, Kabankalan City
Email: [email protected]
Cp #: 0960-6183620
Republic of the Philippines
Department of Education
Region VI-Western Visayas
SCHOOLS DIVISION OF KABANKALAN CITY
INAPOY NATIONAL HIGH SCHOOL
Inapoy, Kabankalan City

Counselor’s Notes:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________

Address: Inapoy, Kabankalan City


Email: [email protected]
Cp #: 0960-6183620

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