Interveiw Paper

NAME_____________________________________

INTERVIEW #1

SOCIAL HISTORY

_____ (15) Followed proper format including areas I-XII

______(10) Description of person involving physical characteristics, sex, race, religion, etc.

______(10) Description of nonverbal behavior: eye contact, open or closed, body posture, mannerisms of hands and feet, tonal quality of speech, etc.

______(5) Clearly stated problem.

______(20) Clearly stating facts using some personal quotes concerning childhood relationships with parents, siblings, peers, and teachers.

______(20) Clearly stating facts and using some personal quotes about:

________(5) Medical/Legal history

________(5) Education

________(5) Employment

________(5) Future plans and aspirations

______(10) Summary statements of about four sentences including inferences by interviewer.

______(10) Recommendations that are specific and numbered if they are in excess of one.

___________GRAND TOTAL