Counseling Center State University of New York at Buffalo
Counseling Center State University of New York at Buffalo
120 Richmond Quadrangle (716) 645-2720
Buffalo, NY 14261-0019
INTAKE WORKSHEET
CASE # V Client ________________________________________________________
Date: ____/____/____
INTAKE COUNSELOR _________________________________ EMERGENCY ____ Yes ____ No
RISK ASSESSMENT “N/A” = not asked or assessed
Current or recent suicidal thought(s)? ___ Y ___ N
Intent? ___ Y ___ N
Plan? ___ Y ___ N
Means? ___ Y ___ N
Has client ever made a suicide attempt in his/her life? ___ Y ___ N
Current or past self-injurious behavior? ___ Y ___ N
Was there a friend/relative who attempted or completed suicide? ___ Y ___ N
Current or past intent to cause damage or harm, threaten,
intimidate or abuse another person? ___ Y ___ N
Any recent losses? ___ Y ___ N
(Note: any affirmative answers to above questions may indicate the need for further assessment and explanation, with additional precautions being taken if required)
Does client have someone he or she can rely on in a crisis? ___ Y ___ N
Relationship: _________________
Additional Information:
History “N/A” = not asked or assessed
Substance abuse history in the family (other than self)? ___ Y ___ N
Has there been a past history of alcohol or substance abuse (self)? ___ Y ___ N
Psychiatric history in the family (other than self)? ___ Y ___ N
Physical abuse? _________ Age(s) ___ Y ___ N
Childhood sexual abuse/incest? _________ Age(s) ___ Y ___ N
Sexual assault/rape? _________ Age(s) ___ Y ___ N
Other significant events:
CURRENT SYMPTOMS
Does client have any health concerns? ___ Y ___ N
Weight/Eating concerns? ___ Y ___ N
Sleep disturbance? ___ Y ___ N
Additional symptoms?
(e.g., anxiety, depression, general mood, fatigue, loss of interest in activities, poor concentration, mental status)
DISPOSITION AT INTAKE
Terminated at Intake ______
Permission to tape: ____audio ____video ____refused both
Counselor recommendations (if any): __________________________________________________________________
Level of motivation
for counseling: Minimal Slightly Moderate Highly
At Counseling Center
____Extended Intake – Date:________________________________________
____Wait List
____Individual Counseling Assigned Counselor_____________________________________________
____Couples counseling Assigned Counselor_____________________________________________
____Group counseling Group Screen date______________________________________________
Group Name___________________________________________________
____Psychiatric consultation Date:___________________________________________________
____Substance abuse consultation Date:___________________________________________________
Community Referral
List referrals made:
Other / Additional Information
____________________________________________________________
Intake Therapist’s Signature
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