Intake Interview for PSY660M

Prepared by Rosalind Espiritu

Date: _________________
Time: _________________

I. IDENTIFYING DATA

Name: _________________________________ Education: grade, ___ high ___, college ___, post grad ___
Age: ____ Birthdate: ________________Ethnic Background & Nationality:___________________
Civil status: single ___, married ___, sep _____
Religion: _______________________________________
Occupation: ____________________________ Legal problem: no, yes ____________________________
Contact no. _____________________________ Interviewee: client, ___ parent ___, sibling ___,
guardian ____, teacher ____, others _______
Address: _____________________________________________________________________________________
____________________________________________________________________________________________

II. REASON FOR REFERRAL

Nature of Problem
____ Academic ____ Adjustment _____Personal
____ Family ____ Behavioral _____Others: ________________________

Presenting Concern
Triggers: ____________________________________________________________________________________
Frequency: __________________________________________________________________________________
Severity: ____________________________________________________________________________________
Duration: ____________________________________________________________________________________
Coping: _____________________________________________________________________________________

III. PERSONAL HISTORY

Family Tree (include name, age, grade/level or occupation of family members, closeness of family relationships,
and discipline methods used by parents):
 Intake Interview for PSY660M
Prepared by Rosalind Espiritu

Family background:
Living conditions:
Living with: ___________________________________________________________________________
Description of neighborhood: _____________________________________________________________
_____________________________________________________________________________________
Significant family events (migration, separation, adoption, deaths, etc.): __________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Developmental concerns (socio-emotional and cognitive): _____________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________

Fears: ______________________________________________________________________________________

Strange experiences (disorientation, hallucinations, etc.): ______________________________________________

____________________________________________________________________________________________

Other concerns: _______________________________________________________________________________

Medical History:
Course of pregnancy: __________________________________________________________________________
Circumstances of delivery: _____normal, ______ caesarian
Family members' past illnesses:
____Past Psych consult ____coffee _____tea
____Past Psych hospitalization ____marijuana _____Benzodiazepines
____Past Intake of Psych meds ____Methamphetamine _____cough syrup
____Past suicide attempt ____herbal drinks _____hair dye
____Allergy ____drive _____medical condition
____Past medical hospitalization ____medication intake _____smoking
____Alcohol ____Others: _____________________________
Client's past illnesses:
____Past Psych consult ____coffee _____tea
____Past Psych hospitalization ____marijuana _____Benzodiazepines
____Past Intake of Psych meds ____Methamphetamine _____cough syrup
____Past suicide attempt ____herbal drinks _____hair dye
____Allergy ____drive _____medical condition
____Past medical hospitalization ____medication intake _____smoking
____Alcohol ____Others: _____________________________

Psychosexual development
First menstrual period: _____________________________________________________
First awareness of sexuality: _____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Sexual activities: ______________________________________________________________________________
____________________________________________________________________________________________
Views of sexual expression: _____________________________________________________________________
___________________________________________________________________________________________
 Intake Interview for PSY660M
Prepared by Rosalind Espiritu

IV. WORK HISTORY

Date Job description Reason for changing job Perception of working environment

V. EDUCATIONAL HISTORY

Date & Year level Description

Honors & awards
Difficult subjects
Subjects with high grades
Subjects with low/failing grades
Interesting/favorite subjects
Relationship with classmates &
teachers

VI. RELIGION/SPIRITUALITY

Spiritual practices engaged in: ___________________________________________________________________

____________________________________________________________________________________________

Significant spiritual experiences: _________________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________

Perception of own religiosity or spirituality: ________________________________________________________

____________________________________________________________________________________________

VII. RECREATION/INTERESTS

Hobbies & interests: ___________________________________________________________________________

____________________________________________________________________________________________

Views towards hobbies & interests: _______________________________________________________________

____________________________________________________________________________________________

VIII. SELF-DESCRIPTION

Strengths & Weaknesses: _______________________________________________________________________

____________________________________________________________________________________________
 Intake Interview for PSY660M
Prepared by Rosalind Espiritu

____________________________________________________________________________________________

Most important decisions & changes in life: ________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________

Plans & dreams for the future:

Five to ten years from now: ______________________________________________________________
_____________________________________________________________________________________
What must be accomplished to make dreams/plans a reality: ____________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________