Intake Form & Questions

Work Status: (Circle all that apply)

1. Currently employed as a_______________________________________

2. Looking for employment as a high school English teacher_________________________

3. Involved with local government agency to find employment

4. Going to college at NAU online __________________________________

5. Obtaining vocational training at_________________________________

Any formal diagnoses: None. I am perfectly healthy.

Any medications (dose and frequency): ___ Imitrex for chronic migraines- 10 mg __________________________________________________________________________________________________________________________________________________________________________________________________

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

I was fired from my teaching job for arguing with my principal in front of others. It was suggested that I need some counseling. I don’t really think that I do, but if it helps me get another teaching job, then I will. I only pointed out to my principal how my way of leading meetings was superior to hers because I had measurable results and she didn’t. I’m the one with the two master’s degrees, one in education and one in leadership. I graduated with honors and have had many of my articles published. She only has one master’s degree in education. I’m working toward my doctorate. I feel I was wrongly fired, but I am here at this agency to obtain counseling. I suffer from chronic migraines and have had trouble sleeping lately, but I think it’s because I am worried about getting another teaching job. I’m pretty concerned that I won’t find another job. I’m not particularly used to failing at a job or anything in my life. I’m fairly accomplished for someone my age. I’m an only child whose parents taught me how to work hard and succeed. They both were medical engineers with advanced degrees. They worked hard to provide a nice life for us in an affluent neighborhood. I value hard work and education. I’ve had to put up with this “competitive” issue from other bosses and even with professors before. I know how to handle these people. It’s probably a feminist thing. My former principal is obviously threatened by my success as a single woman in society today. She’s from another era where women who weren’t married were frowned upon. So, I’m here at this agency for suggestions on how to get along with people so I can get another teaching job.

Any Family History of Mental Illness: My mother suffered from migraines and depression. She was treated in the 1980s for mental illness. She was on strong anti-depressants all her life. She passed away two years ago. She accidently overdosed on pills. It wasn’t considered a suicide.

Possible Services Desired: (Circle all that apply)

**This client may show a sense of self-importance during the interview. She may boast about her accomplishments and show a lack of empathy toward others. She may become combative if pressed about lack of empathy or possible depression issues, especially about her mother’s death. Because she is aggravated, she may shift in her chair, check her watch, and appear cautious about questions. As the interviewer, you will need to use engagement strategies to help you stay on track toward the identified problem.

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