Intake Form & Questions

Marital Status: (circle) Single Married Separated Divorced

Email: [email protected]

Address: 1234 W. Idunno Drive Denver, CO 56789

Phone: (602)555-5678

Work Status: (Circle all that apply)

1. Currently employed as a IT Tech for Faculty Services at West Community College

2. Looking for employment as __________________________________________

3. Involved with local government agency to find employment

4. Going to college at ___________________________________________

5. Obtaining vocational training at_________________________________

Any formal diagnoses: High blood pressure/hypertension.

Any medications (dose and frequency): ___ Lisinopril for high blood pressure

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

I’m here because my boss says my work is suffering lately. He said I’m coming in late and leaving early and that “something must be wrong” with me. I put in my hours, so I am only here to satisfy the requirement by Human Resources. Everything is fine. I haven’t been sleeping well, lately, so I’ve been staying up later than usual. They’re moving me to a new department next month, so I won’t be working with my group. I have a feeling it’s racial. I’m the only minority in our small department. I’m not happy about that but I have no say in it. My father taught me and my brother how to handle racism. We lived in a poor neighborhood as kids and had to defend ourselves against the upper-class kids. I know how to handle racism, but this is different. I don’t feel comfortable speaking out at work. I value my job and am committed to working hard. I want to earn a manger promotion someday. I’ve been here long enough to be a manager. My ex-wife has been complaining a lot lately about my anger issues. She said our kids (boy age 13 and a girl age 15) have expressed some concerns, but I think she’s making it all up. So, I’m here to fulfill the HR commitment and not get fired from my job. I guess I wouldn’t mind talking to someone about things now and then as long as it’s confidential.

Any Family History of Mental Illness: My mother suffered from depression, but she’s on meds now and everything is fine.

Possible Services Desired: (Circle all that apply)

**This client may be passive at first and the interviewer will need to use engagement strategies to make him feel safe enough to share. If pressed too hard about anger issues, he could become combative during the interview. Because he is cautious, he may not be able to hide his discomfort and may wring his hands, tap his foot, glance at his watch, or shift in his chair frequently. The interviewer will need to know how to handle this behavior and use engagement strategies to stimulate discussion in order to uncover the identified problem.

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