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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