INTAKE INTERVIEW QUESTIONS: - Squarespace
INTAKE INTERVIEW QUESTIONS:
The following questions may help me to better assist you in the counseling process. If for any reason, you do not want to answer the questions, you do not have to. You may leave any question blank. During the course of therapy, I may ask follow up questions based on your answers. Again these questions and the answers you provide may likely increase my ability to be helpful.
Client Name:__________________________________ Date: __________________
Age: _______
Who suggested you come to see me? _________________________________________
OK to thank referral? ______ Yes _______ No
In your own words, why are you seeking counseling at this time?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you had counseling in the past? _____ Yes _____ No
Who did you see? ___________________________________
Approximate dates: ______________________________
Was it a good experience? _____ Yes _____ No
Why or why not? _________________________________________________________
Please list any medications you are currently taking:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever gone to the hospital for mental health reasons? _____ Yes _____ No
Have you ever gone to the hospital for substance abuse reasons: _____ Yes _____ No
Approximate dates: ______________________________
Where did you go? _______________________________
In your own words, what do you hope to gain from being in counseling? ________________________________________________________________________________________________________________________________________________________________________________________________________________________
What do you see as your strengths? (for couples, please also identify relationship strengths).
________________________________________________________________________________________________________________________________________________________________________________________________________________________
If you or any of your family has a history of any of the following, please indicate and briefly describe:
Health problems:
Mental health problems:
Substance abuse problems:
History of abuse (physical, emotional, or sexual):
Legal problems:
Economic problems:
Occupational problems:
Housing problems:
Thank you for taking the time to complete this form. We can talk about your reactions and any concerns in our next session.
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