IntakeInterviewPlan.docx

Intake Interview Plan – M. Harris

Welcome/Greeting

Review Purpose of Intake Interview

Obtain Verbal Consent for Recording

Begin the recording

Demographic Questions

Name,

Address,

Dob,

Age,

Phone number,

Occupation,

Employer,

Emergency contact name and phone number

Reason for seeking therapy or reason for referral

Current Situation and Functioning

Living situation,

Daily activities at work,

Daily responsibilities at home,

Daily responsibilities at work,

How do you manage stress,

How do you feel today?

oThis week?

oWhat emotions have you experienced day/week/month?

oHow do you feel most days?

What are your strengths work & personal?

What are your weaknesses work & personal?

How do you manage adversity at work and at home?

How are you sleeping?

Do you have trouble falling asleep, staying asleep, waking up?

How is your energy level though the day?

do you have enough energy to get things done?

How is your appetite?

Current Medical History

Medical conditions

Diagnoses

Hospitalizations

Prescribed Medications

New or unexplored physical symptoms

Past Medical History

Medical conditions

Diagnoses

Hospitalizations

Prescribed Medications

New or unexplored physical symptoms

Psychiatric Treatment History

Any psychological testing

Past counseling

Hospital Admissions

ER visits

Suicide Attempts

oPast

oPresent

Suicidal Thoughts

oPast

oPresent

Suicide Plan

oPast

oPresent

oDo you have the means?

Family History

Mother

Father

Grandparents

Siblings

Aunts & Uncles

Extended family

Any family members with mental health conditions?

oWho, what condition, how were they treated?

Social and Developmental History

Pregnancy

Birth

Infancy/Toddler

Childhood

Teens

Adulthood

Educational & Occupational History

Preschool

Kindergarden

Elementary School

Middle School

High School

Post Secondary Education

First job

Current job

Career Aspirations

Conclusion

Anything else you want me to know?

Anything I forgot to ask?

Miscellaneous Questions

Are there things that worry you a lot?

Have you ever felt an intense fear or worry that something bad would

happen to you?

Are there specific things that frighten you?

Do you ever feel the need to do something over and over until it's

perfect?

Are there certain things you sometimes feel compelled to do over and

over?

Are there ever thoughts that you just can't get out of your head?

Have you ever felt someone was reading you mind or making you think

things?

Have you ever felt your mind was playing tricks on you?

Have you ever had a dream that was so intense and real, you weren't

sure if you were asleep or awake?

Do you think your eating habits are unusual?

What is your weight now?

What is the most and least you've weighed?

Are you concerned about your weight?

Do you ever find yourself suddenly doing something before you have

really had a chance to think about it?

Do you ever do things you had decided not to do, and don't know why?

Does money "burn a hole in your pocket"?

Have you ever had so much energy you couldn't sit still?

That you didn't need to sleep for days at a time?

When you enter a building or get on a bus, does everyone turn to look

and watch you. Do you think someone is out to get or harm you, or is

plotting against you? Have you ever done something unusual, and

thought someone might have drugged you to make you do it?

3 strengths/reasons to hire you

3 weaknesses/things you'd change

Smartest/dumbest thing you ever did

3 wishes/invisible for a day

What would be on your tombstone/obituary

What role do you play in your difficulties

What would you do if you won the lottery

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