Intake Report, Initial Interview
COUC 521
Benchmark Intake Report Part One: Initial Interview Assignment Template
Identifying Information
Client name, address, phone number, DOB, gender, marital status, occupation, work/school, work phone, emergency contact, date of interview
Reason for Referral
Referral source, reason for referral (why has the client been sent to you [e.g., consultation, clinical intake, counseling]); presenting complaint (hint: they are coming in for an evaluation)
Current Situation and Functioning
A description of typical daily activities, ability to complete normal activities of daily living (ADLs); general assessment of coping/character skills (e.g., stress management skills, emotional regulation ability; problem-solving, conflict resolution, empathy, cooperation, etc.); self-perceived strengths and weaknesses
Relevant Medical History
Previous and current medical problems (major illnesses and injuries), medications, hospitalizations, and disabilities; any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease, etc.)
Psychiatric Treatment History
Description of previous treatment received, including hospitalization, medications, psychotherapy or counseling, case management, etc. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins)
Family History
Information about the client’s family background, including information about first-degree relatives (parents, siblings), the composition of the family during the client’s childhood and
adolescence, and the quality of relationships with family members both past and present.
Social and Developmental History
Significant developmental events that may influence current problems or circumstances. This should include, as aplplicable, issues surrounding pregnancy or birth; social, behavioral, and cognitive milestones; and relational history (include interaction with peers, people in authority, academic performance, and extra-curricular activities – e.g., sports, clubs, etc.); current and previous marital/non-marital relationships, children, and social supports.
Educational and Occupational History
Schools attended, educational level attained, and any professional, technical, and/or vocational training; current employment status, length of tenure on past jobs, military service (rank and duties), job performance, job losses, leaves of absence, and occupational injuries.
Cultural Influences
Potential assessment issues (see chapter 3) when working with a diverse populations.
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