INTAKE FORM12
Name: ___________________________ Date of Birth: ________________________
Age: _____________________________ Date of Intake:________________________
Intake Interviewer: ___________________ Date of Report:_______________________
I. Identifying Information and Reason for Referral
A. Client name
B. Age
C. Gender Identity
D. Racial/Ethnic information
E. Relationship status
F. Referral source
G. Reason for referral (why has the client been sent to you for a consultation/intake
session?)
H. Presenting complaint (use a quote from the client to describe the complaint)
II. Behavioral Observations (and Mental Status Examination)
A. Appearance upon presentation (including comments about hygiene, eye contact, body
posture, and facial expression)
B. Quality and quantity of speech and responsivity to questioning
C. Client description of mood (use a quote in the report when appropriate)
D. Primary thought content (including presence or absence of suicide ideation)
E. Level of cooperation with the interview
F. Estimate of adequacy of the data obtained
III. History of the Present Problem (or Illness)
A. Include one paragraph describing the client’s presenting problems and associated
current stressors
B. Include one or two paragraphs outlining when the problem initially began and the
course or development of symptoms
C. Repeat, as needed, paragraph-long descriptions of additional current problems
identified during the intake interview (client problems are usually organized using
diagnostic—DSM—groupings, however, suicide ideation, homicide ideation,
relationship problems, etc., may be listed)
IV. Past Treatment (Psychiatric) History and Family Treatment (Psychiatric) History
A. Include a description (no more than 1 paragraph) of previous clinical problems or
episodes not included in the previous section (e.g., if the client is presenting with a
problem of clinical anxiety, but also has a history of treatment for an eating disorder,
the eating disorder should be noted here)
1
Adapted from Sommers-Flanagan and Sommers-Flanagan (2017)
2
Please delete italicized notes in your final submission. These are being provided here to support your writing only.
B. Description of previous treatment received, including hospitalization, medications,
psychotherapy or counseling, case management, etc.
C. Include a description of all psychiatric and substance abuse disorders found in all
blood relatives (i.e., at least parents, siblings, grandparents, and children, but also
possibly aunts, uncles, and cousins)
D. Also include a list of any significant major medical disorders in blood relatives (e.g.,
cancer, diabetes, seizure disorders, thyroid disease)
V. Relevant Medical History
A. Past hospitalizations and/or major illnesses (List and briefly describe past
hospitalizations and major medical illnesses - e.g., asthma, HIV positive,
hypertension)
B. Current health status (it’s good to use a client quote or physician quote here)
C. Current medications and dosages
VI. Social and Family History
A. Early memories/experiences (including, when appropriate, descriptions of parents
and possible abuse or childhood traumatization)
B. Educational history
C. Employment history
D. Military history
E. Romantic relationship history
F. Sexual history
G. Aggression/violence history
H. Alcohol/Drug history (if not previously covered as a primary problem area)
I. Legal history
J. Spiritual/Religious history
VII. Current Situation and Functioning
A. Daily activities (a description of typical daily activities)
B. Self-perceived strengths and weaknesses
C. Ability to complete normal activities of daily living
VIII. Diagnostic Impressions
A. Brief discussion of diagnostic issues – for the purposes of this assignment, am less
interested in your diagnostic ability, but briefly articulate some of your general
diagnostic impressions based on the information that you have obtained thus far
IX. Case Formulation
Include a paragraph description of how you conceptualize the case. This description will
provide a foundation for how you will work with this person. For example, a behaviorist will
emphasize reinforcement contingencies that have influenced the client’s development of
symptoms
and that will likely aid in alleviation of client symptoms. Alternatively, a psychoanalytically-
oriented interviewer will emphasize personality dynamics and historically significant and
repeating relationship conflicts.
