L12A62

PRE-INTAKE INTERVIEW QUESTIONS (for the role of the Client):

Client Name: Jamilah St Juste Date: July 22, 2022. Age: 15

In your own words, why are you seeking counseling at this time? My case manager recommended me for services because of my father’s conviction.

Have you had counseling in the past? Yes

What for? For my depression

Was it a good experience? Yes

Why or why not? It was good because I had someone to talk without getting in trouble for it.

Please list any medications you are currently taking: Escitalopram (Lexapro)

Have you ever gone to the hospital for mental health reasons? No

Have you ever gone to the hospital for substance abuse reasons: No

In your own words, what do you hope to gain from being in counseling? I want to feel good about myself and my life. So much has happened and I want to get through it.

What do you see as your strengths? (For couples, please also identify relationship strengths).

I think I’m strong and resilient.

If you or any of your family has a history of any of the following, please indicate who:

Health problems: Mom Mental health problems: Me, Dad, sibilings

Substance abuse problems: Dad History of abuse (physical, emotional, or sexual: Me and Siblings, Mom

Legal problems: Dad Economic problems: dad, mom, older brother Occupational problems: Dad Housing problems: me and sibilings

Thank you for taking the time to complete this form. We can talk about your reactions and any concerns in our session. (Semmler, n.d., amended by H. Hill)