11/5/23, 2:13 PM
Bolton L COUC521 Intake Interview Template
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Intro:
Lenny, Registered Alcohol and Drug Technician, I’ve worked in the mental health setting
for about 2 years now including milieu, mental health, and correctional facilities.
We’re here for the intake assessment, all that means is that we’re going to be having a
conversation so that I can get to know a little more about you, does that sound okay?
At the end of the session, if you have any questions, I’ll be more than happy to answer
them and if I don’t know the answer I’ll consult with my supervisor and colleagues to get
that for you in a timely manner. Does an email or a phone call work best for you?
Next, we just have to do some housekeeping things first is confidentiality
Confidentiality:
As you may know, what we talk about in our sessions is confidential and stays between
you and me.
However, there are a few incidents where I am legally obligated to break confidentiality
and those are:
oAny suicidal or homicidal thoughts or ideations (which is harm to yourself or
another)
oAny suspicion of abuse
oAnd lastly, for legal reasons such as a subpoena by a judge
Demographic information:
Gretchen Miles (spelled and pronounced correctly?)
Date of Birth:
Gender pronouns: she/her
Marital Status:
Referral source:
Primary reason for appointment:
What brought you in today? (in clients own words)
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How long has this been causing distress?
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If prolonged amount of time: why now?
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