Sample Applicant Interview Questionnaire Form



This guidance document for a clinical interview provides examples of the types of questions you could ask. Guidance: In preparation for the clinical interview, carefully review the materials below to identify disclosed diagnoses, symptoms, and behaviors of possible concern. Make sure you ask about ALL disclosed symptoms and behaviors.Forms reviewed for disclosure of applicant’s conditions/diagnoses:? ETA 6-53 ? CCMP(s) for _____________________________________________________________? 504/IEP ? Other (specify): __________________________________________________________Introduce yourself and role on center and share that the purpose of the applicant file review process and interview is to gather information about the diagnoses, symptoms, and behaviors disclosed by the applicant to assess how he/she is doing at this time. IMPORTANT: Determine if the applicant needs communication accommodations before starting the interview. If during the course of the interview, you determine that the applicant needs communication accommodations, please provide them and note them on the last page after the mental status exam.Additionally, if you are aware or suspect that an applicant may have cognitive impairment, then asking questions about adaptive behaviors will be important. Appendix 1 at the end of this document provides sample questions to assess an applicant’s ability to perform specific self-care and social tasks as well as make appropriate safety judgments.Brackets & underline indicate information that should be filled in such as [disclosed diagnosis/condition].Bold questions have follow-up questions. Bold italics (If no…, If yes…) provide direction about which question to ask next.Blue italics provide instructions about specific actions: what to ask or do, or which question to skip to next.Intro/General QuestionsHow did you get interested in the _______________________ Job Corps Center? What makes you want to come here? What would you like accomplish if you come to Job Corps?? HS diploma ? GED ? trade interests _________________________________________ How did you get interested in [trade]?It has been a while since you completed the application for Job Corps. Has anything changed since you completed the paperwork with the Admissions Counselor (AC)? ? Yes? NoIf yes: Tell me what’s changed: Academics/Education/SocialAre you currently in school? ? Yes ? NoIf yes: What has school been like for you?If no: When did you leave school?What was school like for you?What caused you to leave school?Have you ever lived in a dormitory or room with other students? ? Yes ? NoIf no: What do you think it would be like to have 1 to 3 roommates? If yes: What was that like for you? What have you been doing with your time during the past year?What is a typical day like for you? If needed, ask follow-up questions to find out if applicant has a regular routine and sleep habits, such as, “What do you spend most of your time doing? What time do you usually get up? What time do you usually go to bed?”Do you remember watching a video about Job Corps at the AC’s office? The video showed a typical day in Job Corps where students wake up early. What would it be like for you to get up at 6:30 am each day and have a structured routine?Stress/CopingGoing through transitions, like starting at Job Corps, can be stressful. What kinds of things stress you out?What do you do to handle stress? What have you tried that has been helpful? What things have you tried that were not helpful or didn’t work?Mental Health History/Current SymptomsWhen you applied for Job Corps, you filled out a form or talked to the AC about your health. I had a chance to review that paperwork and any records the AC sent. I’d like to ask you some questions about the mental health conditions that you told us about or were in your medical or school records. From the paperwork you completed and from our discussion, I see you have been diagnosed with________________________________________________________________________________Is this correct? ? Yes ? NoIf no: It says that you have [disclosed condition/diagnosis] in the paperwork you submitted. Do you know why it would say that?If yes: When did that first start? Around what age were you diagnosed, or a doctor told you about it?Related to your [disclosed condition/diagnosis] what symptoms or problems are you having right now? Give applicant choices about symptoms related to the specific disorder(s).For example, are you still having trouble with [symptom]? [Examples: sad mood, thoughts about wanting to die, panic attacks, getting angry easily or having a hot temper, feeling irritable/like little things get on your nerves, seeing or hearing things that are not really there, etc.?]List specific symptoms/behaviors associated with each of applicant’s disorders. a)b)c)d)e)f)g)h)I am going to go through a list of problems that some people may have. Let me know which ones you are currently having due to your [disclosed condition/diagnosis]. Do you …?Check all positive responses and complete columns.Symptom/BehaviorResponseIF YES,Last time this happened?How often? (daily, weekly, monthly)How much of a problem on a scale 1-10?Have trouble getting along with others your age?? Yes ? NoHave trouble getting along with adults?? Yes ? NoHave a hard time being in large groups of people or in social situations?? Yes ? NoHave a hard time handling stress?? Yes ? NoHave a hard time managing feelings or moods such as anger or depression?? Yes ? NoHave trouble with mood swings?? Yes ? NoHave a hard time expressing what you want to say in words?? Yes ? NoHave a hard time understanding what other people are saying?? Yes ? NoGet into trouble because of bad decisions?? Yes ? NoHave problems with being sensitive to loud noises, lights, people touching you, or other things?? Yes ? NoHave problems with remembering things?? Yes ? NoHave problems with concentrating or staying focused on something for a period of time?? Yes ? NoHave trouble falling asleep or staying asleep?? Yes ? NoHave problems with getting tired easily?? Yes ? NoNeed help taking care of yourself (getting up in the morning, showering, dressing, etc.)? Yes ? NoHave trouble handling it when things change unexpectedly – when things switch up?? Yes ? NoHave problems with organizing things or staying organized – like organizing your time or keeping up with your things (cell phone, keys, glasses)?? Yes ? NoHave a hard time taking directions from adults in charge?? Yes ? NoHave panic attacks?? Yes ? NoHow do the [symptoms/behaviors] that we just talked about get in the way of you doing your everyday activities or other things you want to do (going to school, getting a job, etc.)?Are you currently or have you recently been in counseling or therapy for any of the problems that we just talked about?If no: Skip to question 16. If yes: Tell me about it.How often do you go?Who is/was your doctor/counselor/therapist?? Yes ? NoHow does/did your doctor/counselor/therapist help you with your [diagnosis/condition]?Do you have any follow-up appts scheduled? If yes: When is your next appointment?? Yes ? NoHave you ever been in counseling at all for any reason?If no: Skip to question 17. If yes: Tell me about it.How often did you go?What it helpful? ? Yes ? NoAre you currently or have you recently been taking any medications for your [disclosed condition/diagnosis]?? Yes ? NoIf no: Have you ever taken any medications for a mental health condition? If no to this follow-up question: Skip to question 18 (next page).? Yes ? NoIf yes: What medications are you taking now or did you take in the past?Do you know the dose(s) and how often you take it? ? Yes ? NoDo you take your medication(s) the way your doctor told you to?If no: Why not?? Yes ? No Does anyone help you with your medications?If yes: Who and how do they help you?? Yes ? NoDo you have a doctor or someone else who checks to see how your medications are working for you?? Yes ? NoHave you ever been hospitalized for treatment of your [diagnosis/condition]?If no: Skip to question 19. If yes: Tell me about that. When was the last time you were in the hospital?? Yes ? NoWhen you were released from the hospital, what kind of treatment did they tell you follow up with – like go to counseling or go see your regular doctor or go see a psychiatrist? Did they make any appointments for you? (i.e., discharge recommendations)Did you follow through with the treatment that was recommended for you after the hospital?If no: Why not?? Yes ? NoHave you ever had any other kind of treatment for your [condition/diagnosis]? (like going to a residential treatment center or group home or doing home remedies or cultural practices)?If no: Skip to question 20. If yes: Tell me about it:? Yes ? NoRepeat questions #15-19, as needed, for each endorsed or disclosed condition.Have you ever had thoughts of wanting to die or end your life?If no: Skip to question 21 (next page). If yes: Tell me about that:? Yes ? NoHow often do you have had these kinds of thoughts?When was the last time you had these thoughts?Did you ever have a plan of how you would end your life?If yes: Please explain:? Yes ? NoHave you actually ever tried to end your life?If no: Skip to question 21. If yes: How and when?If yes: What happened afterwards?? Yes ? NoHave you ever physically hurt another person? If no: Skip to next section. If yes: Tell me about that:? Yes ? NoWhen was the last time this happened?How many times has that happened?Alcohol/Drug UseI have just a few more questions. I’d like to ask you about your use of alcohol or drugs. ? Denies use of alcohol/drugs. Skip to question 25 (next page).Do you drink alcohol?If no: Skip to question 23. If yes: Tell me about that:? Yes ? NoHave you ever had any kind of problems (like family problems, relationship problems or legal problems) because of your alcohol use?If yes: Tell me about that:? Yes ? NoAre you currently or have you ever used drugs of any kind?If no: Skip to question 24 (next page). If yes: Which ones?? Yes ? NoHave you ever had any kind of problems (like family problems, relationship problems or legal problems) because of your alcohol use?If yes: Tell me about that:? Yes ? NoHave other people expressed concern regarding your alcohol or drug use?If yes: Who and why?? Yes ? NoHave you ever been in treatment for alcohol or drug use?**If yes: Tell me about that:? Yes ? No**If applicant has a history of substance abuse treatment, TEAP Specialist will likely need to be involved in AFR for this applicant.If there anything else that I didn’t ask you about that you would like to share with me, anything you think it would be helpful for me to know about you? ? Yes ? NoThank you for taking the time to answer all of my questions. Do you have any questions for me?? Yes ? NoIMPORTANT! Complete Mental Status Exam on next page (As best as possible if over phone)* Indicates areas that cannot be assessed during a telephone interview.Appearance*RapportBehavior*MoodAffect*? Appropriate hygiene & dress? Poor hygiene? Unkempt? Disheveled? Inappropriate dress? Unusual hairstyle or color? Body art/tattoos? Seductive? Unable to assess? Cooperative? Engaged? Resistant? Avoidant? Apathetic? Dismissive? Distant? Evasive? Mistrustful? Guarded? Hostile ? Appropriate/WFL? Anxious/Tense? Restless? Impulsive? Hyperactive/fidgety? Agitated? Aggressive? Withdrawn? Lethargic? Yawning? Hair twirling? Nail biting? Picking? Histrionic? Bizarre? Tics? Tardive dyskinesia? Unable to assess? Euthymic? Cheerful/positive? Euphoric? Elevated? Depressed? Anxious? Irritable? Angry? Labile? Full range? Congruent w/ mood/content? Expansive? Constricted? Blunted? Flat? Labile? Incongruent w/ mood/content? Unable to assessEye Contact*Alertness/OrientationIdeationInsight? Good? Intermittent? Poor? Avoidant? Intense? Unable to assess? Alert & oriented x 4? Drowsy? Sedated? Not fully oriented ? Not assessed? Suicidal ideation? with plan? with intent? Homicidal ideation? with plan? with intent? WFL/age-appropriate? Fair? Lacking? Poor? Unable to assessSpeechLanguageCognitionThought ContentPerceptual? Clear? Rate, prosody & volume WFL? Mumbled? Pressured? Rapid rate? Slow rate? Slurred? Halting? Stammering? Stuttering? Soft volume? Loud volume? Lack of prosody? Receptive/ comprehension WFL? Expressive WFL? Required repetition? Required rephrasing? Delayed responses? Word-finding difficulties? Limited vocabulary? Circumlocution? Rambling? Excessive? Word salad? WFLImpaired:? Attention/ distractibility? Concentration? Abstract thinking? Judgment? Recent memory? Remote memory? Logical, coherent & goal-directed? Concrete? Disorganized? Tangential? Incoherent? Perseverative? Flight of ideas? Loose associations? Paranoia? Ideas of reference? Bizarre? Delusional? Depersonalization? Derealization? WFLHallucinations? Auditory? Visual? Other? Not assessedSensory/Physical*? No limitations noted? Visual? Hearing? Physical? Speech? Self-reported? Unable to assessWere communication accommodations needed?? Yes ? NoWere communication accommodations provided?? Yes ? NoIf yes, please check which accommodations were provided:Slower rate of speech? Yes ? NoRepetition of questions? Yes ? NoRephrasing questions? Yes ? NoUse of simpler language? Yes ? NoProvided more time for processing or responses? Yes ? NoOther: ______________________________________? Yes ? NoAppendix 1: Adaptive Behavior QuestionsNow I’d like to ask you about some tasks that people do every day. I want to know how much help, if any, you need from other people to do these tasks. There are no right or wrong answers. It is important for me to get a clear idea of how much help you might need if you come to Job Corps. Do you need any help at all, even if it is just a little bit, with: ActivityNo Assistance NeededSome AssistanceComplete AssistanceDoes Not DoWho helps you with that?Bathing: How do you do with things like wash your face, take a shower or bath, and wash your hair?Do you need reminders to do these things? Yes NoGrooming: How do you do with combing your hair? Put on deodorant (Females – taking care of your monthly period?)Do you need reminders to do these things? Yes NoEating: How do you do with going through a cafeteria line and picking out food to eat?Shopping: Are you able to buy what you need at Walmart or the grocery store like soap, shampoo, deodorant, clothes and shoes?Do you need reminders to buy what you need? Yes NoManaging medications: How do you do with taking your medicines the way the doctor told you to? Do you take them on your own or does someone remind you?Using the phone: How do you find a phone number that you don’t have (like to a drug store)? Could you find the number if you needed to?Housework: Do you make up your own bed? Do you know how to wash the dishes? Do you know how to use a broom or mop or a vacuum cleaner? Do you know how to clean a sink or toilet?Do you need reminders of when to perform these tasks? Yes NoLaundry: Do you wash your own clothes? How do you do with that? Do you know how to sort clothes and use a washer and dryer?Managing money: Do you manage your own money? Do you pay any of your own bills like your cell phone bill?Driving/transportation: Do you know how to drive? Can you get where you want to go using a city bus or other public transportation? Could you get or arrange a ride to a place that the bus doesn’t go if you need to?Controlling anger: Do you tend to get angry when plans change or when things don’t go your way? What things do you to do to stay in control when you are angry?Adjusting behavior: When you know that others are nearby and are busy and doing something, {can you give them space and not interrupt?}Social: In a social or group situation, how can you tell if it is OK to try to join a group or if it is a group that you should stay away from? (Stays out of a group that is non-welcoming) Do you know when to stay out of groups engaged in risk behaviors? For example: alcohol or drug use, unsafe sexual behaviors.Planning: Do people ever tell you that you need to think before acting—that you get into trouble because you do things without thinking about if it’s really a good idea first?Safety: Have you ever wandered away or found yourself in an unsafe situation? Example: gotten lost, not knowing your way back home. Have you engaged in actions risking your safety? Examples: like almost being hit by a car because you weren’t looking while you were in a parking lot or crossing the street? Or in an unsafe situation with people you don’t know or in a place where you should not have gone?Safety: Have you ever been tricked into doing something that could hurt or harm you? Examples: like has someone ever dared you to do something and you got in trouble or got hurt? Has someone tricked you out of your money? ................
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