INTAKE INTERVIEW

Clients Name:_________________ Date:_________

I. DEMOGRAPHCICS

AGE

GENDER

NATIONALITY

CIVIL STATUS

ECONOMIC
STATUS

EMPLOYMENT
STATUS

RELIGION

EDUCATIONAL
ATTAINMENT

II. PRELIMINARY QUESTIONS

1. What is/are the reason/s for this session? ______________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________
 a. Can you describe the symptoms that you are experiencing: ___________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

2. Have you had any therapy sessions before? ___________________________

a. If yes, with who: _________________________

b. How long was it (give specific dates): ____________________

c. How was the experience: ___________________

3. Are taking any medications right now? _____Yes ____No

a. If yes, what are they: ___________________________________

4. What are stressors in your life currently?

_______________________________________________________________

______________________________________________________________________

5. What do you think is important to know about you?

_______________________________________________________________

______________________________________________________________________

II. MEIDICAL HISTORY

1. Do you have any medical history of any sort or substance abuse history? ___Yes ___No

a. If yes, what are they: _______________________________________

2. Does anyone from your family have any history or medical or mental issues?? ___Yes
___No
 a. If yes, who are they and what are the issues? ______________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

a. Are you part of any social /community support group? If yes, what are they?
_____________________________________________________

3. Did you have any problems or issues that you have encountered (e.g. development
milestone, trauma) during your childhood? If yes, what is/are the usual problems?
_________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

III. SOCIAL/WORK HISTORY

1. How would you describe your social life? ______________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

2. Do you belong to any associations/organizations in your community? If yes, what are

they? ___________________________________________________

_______________________________________________________________

_______________________________________________________________
 _______________________________________________________________

3. What is/are the recreational activity/ies that you enjoy most? _______________

________________________________________________________________

4. Are you currently employed? If yes, what is the nature of your job and how long have you
been there? ______________________________________________

________________________________________________________________

5. Can you describe your working relationship with your colleagues/supervisor?

________________________________________________________________

_______________________________________________________________

6. What do you enjoy about your job? ___________________________________

_______________________________________________________________

IV. FAMILY BACKGROUND

Members of your immediate family:

Family Member Relationship Age Location

V. TRAUMA HISTORY

Have you ever had any thoughts currently or in the past of hurting yourself? If yes, explain

Has anyone tried to hurt you currently in the past? If yes, explain

Do you have any history of present or past sexual abuse? If yes, explain

Have you witnessed or been affected by violence? If yes, explain

Have you experience any other traumatic events? If yes, explain

VI. OTHER

What do you want to change about yourself?

What changes do you hope therapy will lead to?

What are your major strengths?