Intake Interview

Date: ___________________

Personal Information
Name
Age
Gender
Weight
Height
Civil Status
Nationality
Work

Reason for Referral and Presenting Problem

Symptoms/ Description of the problem
Initial Onset
Intensity
Frequency
Duration
Impact on functioning
Contributing factors
Attempts to solve

Personal History
Education

Medical history

Mental Health history

- disease/illness
- treatment history

Substance use history

- type
- first use
- last use
- frequency
- amount
- reason for use
- treatment history

Hobbies/interests/recreational
activities
Family background
Birth order
No. of siblings
Sibling relationship
Parents’ occupation(s)
Parent relationships
- to each other
- to client
- to siblings
Parents current health
Medical history of family members
Urban/rural upbringing
Socioeconomic level
Cultural background

Interpersonal relationships
Peer relationships

Romantic relationships

Workplace relationships

Miscellaneous
Self-concept
Happiest/saddest memories
Earliest memory
Fears
Somatic concerns
Recurring/noteworthy dreams
Events that create happiness/sadness
Goals/Plans
 Mental Status Exam
Appearance Within Norm Notable Details
Grooming
Motor activity
Coordination/Gait
Notes:

Relatedness Within Norm Notable Details

Cooperative Hostile
Friendly Seductive
Relaxed Guarded
Good eye contact Poor eye contact
Notes:

Speech/Language Within Norm Notable Details

Affect Expressive Flat Anxious
Good range Constricted Sad
Angry mood Labile
Incongruent Inappropriate
to situation
Mood Euthymic Elevated Angry
Depressed
Notes:

Thought process Within Norm Notable Details

Goal directed Tangential
Logical Circumstantial
Abstract reasoning Magical
Concrete
Flight of ideas
Slow
Rapid
Loose
Notes:

Thought content Present Not Present Details

Hallucination
Delusions
Depressive Ideation
Suicidality
Aggressiveness
Homicidality
Notes:
Memory Intact Impaired Details
Short-term
Long-term
Notes:

Attention/ Within Norm Notable Details

Concentration
Notes:

Alertness/ Within Norm Notable Details

Orientation Alert Lethargic
Oriented Hypervigilant
Disoriented
Notes:

Judgment/ Within Norm Notable Details

Planning Judgment
Impulse control
Notes:

Insight Within Norm Notable Details

Notes:
I. Diagnosis

II. Differential Diagnosis

________________________________ _______________

Client Signature over Printed Name Date

________________________________ ________________

Janine Alexis Rosco Date