Intake Form & Questions

Marital Status: (circle) Single Married Separated Divorced

Email: [email protected]

Address: 25 N. 19th Street, apt. 2122 Los Angeles, CA 90210

Phone: (212)555-5556

Work Status: (Circle all that apply)

1. Currently employed as a Teacher’s assistant at school_______________

2. Looking for employment as _________________________________________

3. Involved with local government agency to find employment

4. Going to college at University of Los Angeles online ________________

5. Obtaining vocational training at_________________________________

Any formal diagnoses: None. I am perfectly healthy.

Any medications (dose and frequency): None __________________________________________________________________________________________________________________________________________________________________________________________________

Specific concerns: (Provide reasons for today’s visit. Please be specific about work life, school, and family influences):

I’ve been having trouble sleeping lately. My stomach has been bothering me. I think I may have an ulcer. I make myself throw up and my stomach feels better. I recently broke up with my girlfriend and think I may be depressed but I’m not sure. I don’t socialize much anymore. I work out a lot at CrossFit. My girlfriend complained that I work out too much and obsess about food, but physical fitness is my passion. I’m working on an Exercise Science degree because I want to be a personal trainer. She always said my body was fine but I want to be bigger and stronger. I was extremely thin when I was a kid and people made fun of me. My own father teased me a lot when I was in high school because I couldn’t play sports. He would hate it if he knew I was here asking for help. That goes against the family way. I have a strong work ethic and am very disciplined when it comes to exercise and school. My mom taught me to be disciplined. She raised us as a single mom and showed us how to work hard. She inspires me. I have goals that are important to me. I guess I’m here to figure out what those goals are.

Any Family History of Mental Illness: Not that I know of. I think my grandmother suffered from depression and was on medication.

Possible Services Desired: (Circle all that apply)

**This client may be passive at first. He may show signs of discomfort or irritability like shifting in his seat, tapping fingers or feet. He may avoid talking about the breakup with his girlfriend. He may become combative if pressed about a possible eating disorder, so the interviewer will need to use engagement strategies that stimulate discussion in order to find the identified problem. The interviewer must be prepared to suggest social services to the client.

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