Abnormal Psychology
satoru
CaseStudy_MockCounselingIntakeForm.docxJeremy Rottini PSY249
MOCK COUNSELING INTAKE FORM
Name: Age: Gender: Religious Affiliation:
Ethnicity: Asian/Pacific Islander American Indian Hispanic African American Caucasian Other
Relationship Status: Single Married Divorced Separated Widowed Partnered
Referral Type: Self Friend Family School Court Other
Please describe the concerns you would like to discuss with a counselor:
How long have you had these concerns?
Please list the goals you wish to achieve in counseling. Consider the way you would like to feel, problems you wish to solve, and coping skills you would like to learn:
Please rate each, using the following scale: Not at all Mildly Moderately Highly
How serious do you consider your present concern(s)? I-----------------------------------------------------------------------------------I
How motivated are you to resolve your concern(s)? I-----------------------------------------------------------------------------------I
How optimistic are you that this can be resolved? I-----------------------------------------------------------------------------------I
Please answer EACH question:
1) Have you previously been involved in counseling? Yes No
2) Have you ever been hospitalized for mental health reasons? Yes No
3) Do you currently use alcohol or non-prescribed drugs? Yes No
4) Is there a history of mental health problems in your family? Yes No
5) Have you ever been in legal trouble? Yes No
6) Have you ever been abused in any way? Yes No
7) Are you currently taking any prescription medications? Yes No
8) Are your concerns interfering with your grades? Yes No
9) Are your concerns interfering with your ability to stay in school? Yes No
10) Have you ever attempted suicide? Yes No
11) Are you currently suicidal? Yes No
Please check all of your personal strengths:
reliable
organized
sensitive
resourceful
reserved
active
understanding
humorous
generous
patient
adaptable
determined
optimistic
likable
artistic
courageous
practical
mature
friendly
open-minded
motivated
trustworthy
intellectual
assertive
healthy
confident
calm
attractive
introspective
forgiving
loving
kind
loyal
supportive
outgoing
realistic
trusting
responsible
independent
honest
intelligent
sociable
Please check the concerns you would like to explore with your counselor. Then, for checked items only, mark the degree to which the concern is currently problematic for you, using the following scale:
Mild Moderate Serious Severe
1. Relationship difficulties: I-----------------------------------------------------------------------------------I
2. Family problems: I-----------------------------------------------------------------------------------I
3. Depression/moods: I-----------------------------------------------------------------------------------I
4. Suicidal thoughts or concerns: I-----------------------------------------------------------------------------------I
5. Anxiety: I-----------------------------------------------------------------------------------I
6. Stress symptoms: I-----------------------------------------------------------------------------------I
7. Physical health: I-----------------------------------------------------------------------------------I
8. Anger management: I-----------------------------------------------------------------------------------I
9. Academic difficulties: I-----------------------------------------------------------------------------------I
10. College adjustment: I-----------------------------------------------------------------------------------I
11. Cultural adjustment: I-----------------------------------------------------------------------------------I
12. Racial harassment: I-----------------------------------------------------------------------------------I
13. Self-esteem: I-----------------------------------------------------------------------------------I
14. Death or loss: I-----------------------------------------------------------------------------------I
15. Spiritual/religious concerns: I-----------------------------------------------------------------------------------I
16. Eating concerns or body image: I-----------------------------------------------------------------------------------I
17. Alcohol and/or chemical use: I-----------------------------------------------------------------------------------I
18. Self-inflicted harm: I-----------------------------------------------------------------------------------I
19. Sexual abuse or harassment: I-----------------------------------------------------------------------------------I
20. Sexual health: I-----------------------------------------------------------------------------------I
21. Sexual identity: I-----------------------------------------------------------------------------------I
22. Other: __________________ I-----------------------------------------------------------------------------------I
Please share any additional information you feel is important for your counselor to know:
What is the client’s presenting concerns (impact of problem, severity, duration, symptoms, motivation to change, etc.)?
What is the client’s overall life history (significant events such as divorce, loss of loved ones, major changes/adjustments, etc.)
What does the client’s typical day look like (time wakes up, goes to sleep, work schedule, school schedule, etc.)?
How does the client do socially and with regard to their family (friends, family relationships and structure, peers, work relationships)?
Has the client ever been in legal trouble (for what, on probation, history of being incarcerated, etc.)?
What is the client’s education history and goals (current major, learning disability, education goals, etc.)?
Is there a history of mental health problems in the client’s family (whom, diagnoses, medications, treatment, etc.)?
Does the client currently use alcohol or non-prescribed drugs (type used, for how long, frequency, treatment, etc.)?
Has the client previously been involved in counseling or hospitalized (when, with whom, reason, duration, results, etc.)?
Is the client currently physically healthy (conditions or diagnoses, medication, reason, dosage, prescribing doctor, etc.)?
Has the client ever been abused in any way (by whom, type of abuse, was it reported, duration, etc.)?
Has the client ever attempted suicide (how many times, when, hospitalized, etc.)?
Is the client currently suicidal or homicidal (ideation, plan, lethality, intent, safety plan, assessment of hope, reasons to live, etc.)?
Are clinician actions or crisis plans needed? Yes No
What relevant cultural issues are there (age, gender, sexual orientation, spiritual/religious, ethnicity, and/or language issues, etc.)?
What does the client hope to accomplish in counseling?
DSM – V Diagnoses
Code Diagnosis
Diagnostic Rational:
Treatment Goal #1:
Evidence-Based Treatment Strategy:
Treatment Goal #2:
Evidence-Based Treatment Strategy:
Confidential
