GUIDE FOR INTERVIEW

History of Present Illness (HPI)

1. Paano ka napunta dito? Ano ang dahilan?
2. Sino ang kasama mo? Sino nagdala sayo?
3. Kelan ka dinala dito?
4. Alam mo ba ang lugar na ito? (If the answer is no, explain the name and nature
of the center)
5. Sa palagay mo ba meron kang sakit sa pag-iisip?
6. If the answer to #5 is “Yes”, ask... Kelan nag umpisa ang sakit mo?
7. Na-confine ka na ba sa ibang psychiatric hospital nuon? Kung oo, kailan at ilang
beses?
8. If the answer to #7 is “No”, ask...First time mo ba dito? Kung hindi, ilang beses ka
na nadala/na-confined dito? Kelan yung una at kelan yung pinaka huli? Ano ang
dahilan?

Thought Content/Disturbances:
1. Naranasan mo na ba na makarinig ng mga boses na bumubulong sa iyo na ikaw
lang ang nakakarinig o tuwing ikaw mag-isa lang?
2. Kung oo, ano ang sinasabi ng boses at saan nanggaling ang boses? Ano ang
reaksyon mo?
3. Nakakakita ka ba ng mga pangitain na ikaw lang ang nakakakita? Kung oo, ano
ang reaksyon mo?

Take note of the following:

• Mood of the patient
• Affect of the patient
• Speech quality
• Eye-contact
• Orientation to place, date and person
• Behavior/attitude towards testing

For substance abuse history:

1. Umiinom ka ba ng alak? Kung “Oo”, gaano karami/kadalas? Kelan at paano ka
natutong uminom?
2. Ikaw ba ay gumagamit ng ipinagbabawal na gamot? Kung “Oo” ano ang
ginagamit mo? Kelan at paano ka natuto? Gaano kadami/kadalas ang pag-gamit
mo?

Appetite and sleep disturbances:

1. Kamusta ang pagtulog mo? Nakakatulog ka ba ng mahimbing?
2. Kamusta ang pagkain mo? Magana ka bang kumain?

Note: These are only guide questions. You may add other question if it’s deemed to be
necessary.
 Interview Guide

Name: __________________________________________________________
Referred for: __________________________________________________________
Referred by: __________________________________________________________

PHYSICAL APPEARANCE / DESCRIPTION

✓ Clothing_______________________________________________________________
✓ Mood__________________________________________________________________
✓ Affect_________________________________________________________________
✓ Speech quality________________________________________________________
✓ Eye-contact___________________________________________________________
✓ Orientation to place, date, person____________________________________
✓ Behaviour/attitude towards testing___________________________________

HISTORY OF PRESENT ILLNESS

✓ Reason for evaluation

________________________________________________________________________
________________________________________________________________________
✓ Companion ___________________________________________________________
✓ Do know NCMH? Have you been here before?
________________________________________________________________________
________________________________________________________________________
✓ Suicidal ideation/attempt
________________________________________________________________________
________________________________________________________________________

THOUGHT CONTENT/DISTURBANCES

✓ Auditory hallucinations
________________________________________________________________________
________________________________________________________________________
✓ Visual hallucinations
________________________________________________________________________
________________________________________________________________________

SUBSTANCE HISTORY

✓ Alcohol________________________________________________________________
✓ Smoking______________________________________________________________
✓ Drugs__________________________________________________________________

APPETITE/SLEEP DISTURBANCE
✓ Sleeping patterns_____________________________________________________
✓ Eating patterns_______________________________________________________

FAMILY HISTORY
✓ Father_________________________________________________________________
________________________________________________________________________
✓ Mother________________________________________________________________
________________________________________________________________________
✓ Siblings_______________________________________________________________
________________________________________________________________________
 General Observations

PERSONAL DATA
Name: _________________________________________________
Area of Confinement: _________________________________________________
Age / Civil Status: _________________________________________________
Birthdate: _________________________________________________
Birthplace: _________________________________________________
Education Attainment: _________________________________________________
Referred for: _________________________________________________
Referred by: _________________________________________________
Date Examined: _________________________________________________

PHYSICAL APPEARANCE / DESCRIPTION

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

HISTORY OF PRESENT ILLNESS

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SUBSTANCE HISTORY
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

FAMILY HISTORY
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

BEHAVIORAL REPORT
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Prepared by:

___________________________________
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SAMPLE INTAKE FORM

CONFIDENTIAL
==============================================================================

INTAKE FORM

Client’s Name____________________________________________________________

Date____________________________________________________________________

Person Completing Form (if other than client)

________________________________________________________________________

Purpose:_________________________________________________________________

Client No._______________________________________________________________
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Client History and Information

Client No.________________
Date:____________________
• Basic Information:
Client Name:_________________________________________Date of Birth:_____________________
Age:_____________ Gender: [ ] Male [ ] Female Nationality:______________________
Home Address:_______________________________________________________________________
Home Phone Number:_________Email address:______________Cellphone Number:_______________

If the above client is a minor complete the following:

Name of Guardian:______________________Address of Guardian:_____________________________

Guardian’s Contact Number_____________________________________________________________

• Referral Source
Who referred you to our office, or how did you learn about our practice?
____________________________________________________________________________________

Emergency Contact Information

In case of an emergency, who should we contact?
Name:_____________________________________________Relationship:_______________________
Address:____________________________________________Phone Number:____________________

• History Information
Who is providing the history information?
[ ] The client [ ] The client’s guardian [ ] Other_____________________________

Please describe the current complaint or problem as specifically as you can, in your own words.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

How long have you experienced this problem, or when did you first notice it?
____________________________________________________________________________________
What stressors may have contributed to the current complaint problem?
____________________________________________________________________________________

Check all words/phrases that describe what you are experiencing and explain if possible.
⃞ Substance abuse/dependence
⃞ Addiction (internet, porn, shopping, exercise, gaming, gambling, etc.
⃞ Depression/Sad/Down feelings
⃞ High/Low energy level
⃞ Angry/Irritable
⃞ Loss of interest in activities
⃞ Difficulty enjoying things
⃞ Crying spells
⃞ Decreased motivation
⃞ Withdrawing from people/Isolation
⃞ Mood Swings
⃞ Black and white thinking/All or nothing thinking
⃞ Negative thinking
⃞ Change in weight or appetite
⃞ Change in sleeping pattern
⃞ Suicidal thoughts or plans/Thoughts of hurting yourself
⃞ Self-harm/Cutting/Burning yourself
⃞ Homicidal thoughts or plans/Thoughts of hurting others
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⃞ Poor concentration/Difficulty focusing
⃞ Feelings of hopelessness/Worthlessness
⃞ Feeling of shame or guilt
⃞ Feelings of inadequacy/Low self-esteem
⃞ Anxious/Nervous/Tense feelings
⃞ Panic attacks
⃞ Racing or scrambled thoughts
⃞ Bad or unwanted thoughts
⃞ Flashbacks/Nightmares
⃞ Muscle tensions, ashes, etc.
⃞ Hearing voices/Seeing things not there
⃞ Thoughts of running away
⃞ Paranoid thoughts/Thoughts that someone is watching you, out to get you or hurt you
⃞ Feelings of frustration
⃞ Feelings of being cheated
⃞ Perfectionism
⃞ Rituals of counting things, washing hands, checking locks, doors, stove, etc./Overly
concerned about germs
⃞ Distorted body image (believe you are heavier or less attractive than others say you are)
⃞ Concerns about dieting
⃞ Feelings of loss of control over eating
⃞ Binge eating/Purging
⃞ Rules about eating/Compensating for eating
⃞ Excessive exercise
⃞ Indecisiveness about career
⃞ Job problems
⃞ Other:________________________________________________________________

• Previous Treatment
Have you received or participated in previous counseling and/or therapy? [ ] Yes [ ] No
What did you like/dislike about previous treatment?
____________________________________________________________________________________
What did you learn about yourself through previous counseling/treatment that may help you?
____________________________________________________________________________________
Is there any type of treatment you would like to continue?
____________________________________________________________________________________
Have you had hospital stays for psychological concerns? [ ] Yes [ ] No
Are you currently experiencing thoughts of harming either yourself or someone else?
[ ] Yes [ ] No
Have you in the past experienced thoughts of harming either yourself or someone else?
[ ] Yes [ ] No

• Developmental History
Are you aware of any difficulties or complications during the time your mother was pregnant with you?
[ ] Yes [ ] No
If yes, explain:________________________________________________________________________
Do you feel you have completed normal life milestones (school, career, marriage, children, etc.) at
appropriate times?_____________________________________________________________________
Are you satisfied at where you are in your life?______________________________________________
If not, where would you like to be?_______________________________________________________

• Medical History
List any current or important past medications
Medication & Dose:____________________________Response to Medication:___________________
History of serious childhood illnesses:_____________________________________________________

Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during
your life time:
Have you experienced any head injuries? [ ] Yes [ ] No
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Important Details:
If yes, did you lose consciousness? [ ] Yes [ ] No
Have you experienced convulsions or seizures? [ ] Yes [ ] No
If yes, did you also have a fever? [ ] Yes [ ] No
Explain any allergies you have:________________________________________________________________
How would you rate your current physical health?
[ ] Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor [ ] Very Poor
What was the date of your last physical or routine health “check up?”__________________________________
Do you have a primary care physician? [ ] Yes [ ] No
If yes, complete the following:
Name__________________________Address____________________Phone Number______________

• Family History
Birth Location:_______________________________________________________________________
Raised by: [ ] Mother [ ] Father [ ] Step-mother [ ] Step-father [ ] Other:_________________
Relationship with parent figures: (INDICATE if good, fair, poor, close, distant, etc.)
Mother:_________________
Father:__________________
Step-parent:______________
Other:___________________
List your siblings and describe your relationship with them?
(INDICATE if good, fair, poor, close, distant, etc. as nature of relationship.)
Sibling 1 Sibling 2 Sibling 3 Sibling 4
Name of Sibling
Age
Gender
Nature of
Relationship
Any history of neglect, and/or physical, verbal, emotional, spiritual, or sexual abuse?
____________________________________________________________________________________
____________________________________________________________________________________
Any family history of substance abuse, mental illness, suicide, or violence?
____________________________________________________________________________________
____________________________________________________________________________________
Any Additional Family Information:
____________________________________________________________________________________
____________________________________________________________________________________

• Social History
Describe your relationship with peers and/or friends?
____________________________________________________________________________________
____________________________________________________________________________________
How would you describe your social support network?
____________________________________________________________________________________
____________________________________________________________________________________
Describe your hobbies/interests:
____________________________________________________________________________________
____________________________________________________________________________________
Describe any cultural concerns:
____________________________________________________________________________________
____________________________________________________________________________________

• Educational History
When attending school where you:
[ ] In regular classes [ ] Home Study [ ] Special Classes
[ ] Advanced classes [ ] Ever suspended [ ] Placed in alternative school
What is the highest educational level you have completed?
____________________________________________________________________________________
Give any additional important educational information (i.e. Did you like school? Have a learning
disability?)___________________________________________________________________________
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• Occupational History
What is your current employment status?
[ ] Employed Full-Time [ ] Employed Part-time [ ] Unemployed
[ ] Self-employed [ ] Student [ ] Other
Are you satisfied with your employment?_________________If not, why?________________________

• Marital History
Which best describes your marital status?__________________________________________________
[ ] Married, Date:_____ [ ] Never Married [ ] Widowed, Date:____
[ ] Separated,Date:____ [ ] Divorced, Date:____

If you are married, please briefly describe nature of your marital relationship:______________________
If you are married, which best describes your marital satisfaction?
[ ] Poor [ ] Fair [ ] Good [ ] Great
Please list any previous marriages/significant relationships including current:
____________________________________________________________________________________
Name_________________________Date___________________Nature of Relationship_____________
Do you have children? [ ] Yes [ ] No, If yes, How many?______co mplete the following:

(INDICATE if good, fair, poor, close, etc. as nature of relationship.)

First Name
Age
Gender
Nature of Relationship

Are there presently any child custody issues involving you or your family? [ ] Yes [ ] No

• Substance Abuse History

Are you currently or have you ever struggled with substance abuse? (alcohol, tobacco, marijuana,
caffeine, or other) [ ] Yes [ ] No
If you answered yes, please complete the following substance abuse history chart.

Substance Ever Age of Frequency of Amount Used How did you

Used First Use Use (Daily, use it?
Yes/No Weekly, (Smoked,
Monthly) injected, etc.)
Alcohol
Marijuana
Cocaine or Crack
Heroine
Amphetamines
Club Drugs (Ecstasy,
Inhalants, etc.)
Pain Medication
(Oxycontin, Vicodin,
etc.)
Benzodiazepines
Hallucinogens
Others

Have you ever received treatment for substance abuse issue?

Name of Treatment Program______________________________________
Type of Treatment (Rehab, Intensive Outpatient Program, Partial Hospitalization, Halfway
House, Recovery House, Counseling, Methadone, Suboxone)____________________________
______________________________________________________________________________
Date of Treatment (Month, Year)___________________________________________________
Outcome?_____________________________________________________________________
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• Legal History
Do you currently have any pending criminal charges? [ ] Yes [ ] No
Are you on probation? [ ] Yes [ ] No
Have you ever been arrested/convicted of a crime? [ ] Yes [ ] No
If yes, complete chart. [ ] Yes [ ] No

List any Date of Outcome

Arrests/Conviction Arrests/Convictions

• Additional Information
Summarize your goals for counseling/therapy:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name 5 things you would like to change about yourself.

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

What are your strengths?

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

What are your weaknesses?

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Is there any additional information that you believe it is important for your counselor to know in order to
provide you with the best care possible?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Signature of the client or guardian Date