Unit 5 Assignment: Client Interview

INTAKE SUMMARY

Client Name: Intake Date:

Intake Counselor:

Identifying Information

Demographic Information:

Description of Client:

Presenting Problem/Relevant History

Summary of Presenting Problem:

Relevant Additional History:

Client’s Goals for Counseling:

Crisis Plan (if relevant):

Additional Information:

___________________________ _____________

Counselor’s Signature Date Submitted

�PAGE \# "'Page: '#'�'" ��age, gender, race, marital status, yr. in school, living situation, referral source, new or returning client, etc.

�PAGE \# "'Page: '#'�'" ��physical appearance, dress, manner of expression, quality of interaction with therapist, mental status, etc.

�PAGE \# "'Page: '#'�'" ��include duration, course, symptoms, behavioral aspects, triggers, current attempts to cope, stressors, etc.

�PAGE \# "'Page: '#'�'" ��Social, Vocational/Academic, Family // Significant developmental, educational, vocational milestones, traumas // Substance Use // Past treatment, hospitalizations, medications // etc.