Designing an Intake Process

sampleIntakeForm.doc

Sample Intake Form: Not for actual use.

PRESENTING COMPLAINT: __________________________________________________________________________

Psychological:

DEPRESSION: Appetite Change Depressed Affect Anhedonia Sleep Disturb. Low Energy Conc./Memory

Social Withdrawal Suicidal Thoughts Hopelessness Helplessness Crying Onset ___________________________

Recurring: Y/N

ANXIETY: Ruminating Nervousness Worry Panic Attack Avoids Situations PTSD Onset: ____________________

SLEEP QUALITY: Good Difficulty Falling Asleep Wakes up early Nightmares Onset: ______________________

OTHER: Anger Irritability Mania ___________________________________________________________________

Guilt Perfectionism//Eating Abuse/Trauma Addiction: Gambling Pornography Shopping

Family history of psychological problems: Y/N

If yes, please describe: ___________________________________________________________________________________

Current Stress: ______ Stressors: ____________________________ Coping: _____________________________________

Self-Esteem: __________________________________________________________________________________________

Appearance: Well-groomed Unkempt Unusual Other: _____________________________________________

Cooperation: Cooperative Indifferent Dependent Defiant Manipulative Guarded Hostile

Affect: Normal Flat Blunted Constricted Labile __________________________________________________

Speech: Normal Slow Too detailed Pressured Incoherent Slurred Perseverating

Mood: Normal Depressed Anxious Euphoric/Manic _____________________________________________

Thought Content: Coherent Illogical Delusions Hallucinations___________________________________________

Orientation: Person _____ Place______ Time______

Judgment: Intact Impulsive Immature Impaired __________________________________________________

Motor: Relaxed/calm Restless Agitated Tense Tremors Tics ______________________________________

Attention/Concentration: Normal Mildly Distractible Majorly Distractible

Employment: Title: ______________________ Tenure: ________ In field: ______ Work supportive: Y/N ___________

_____________________________________________________________________________________________________

Education: Highest Grade: _______________________ Special Ed: Y/N Held back: Y/N LD: Y/N _______________

Medical: _________________________________________________ Allergies: Food____________ Meds_____________

Meds: ________________________________________________________________________________________________

Hit in Head/Knocked Unconscious: Y/N __________________________________________________________________

Current Exercise: Y/N Type: ____________ Frequency: ____________ Duration: ____________ Onset: ___________

Previous Counseling:

Type: ______________ Date: ______________ # Sessions: ___________ Response: _____________________________

Suicide Attempt: Y/N __________________________________________ Homicide Attempt: Y/N __________________

Spiritual Life: _________________________________________________________________________________________

Substance Abuse:

Nicotine: Y/N Frequency: _______________________________________________________________________________

Alcohol: Y/N _____________________________________________ Past: ______________________________________

Drugs: Y/N _________________________________ Past: ____________________________________________________

Legal: _______________________________________________________________________________________________

Notes: _______________________________________________________________________________________________

______________________________________________________________________________________________________