Having an effective new-client intake process is a key step towards establishing the therapeutic relationship as well as gaining a first glimpse of who the client is, relevant history, pressing concerns, and what they are hoping to get out of therapy. I believe that the most important data to be gathered here are such items as general information (age, gender, ethnicity, etc.), current symptoms and concerns, current medications, previous counseling experience, previous medical and psychological history, current relationship status, family situation, etc. In addition, giving the client an idea of how the therapeutic process will go, what they can expect from the therapist and the therapy sessions, and a clear statement of confidentiality are important to being building rapport and trust.
The first 10-12 minutes of an intake session provide a first impression of the client to you and of you to the client. As Vriend and Kottler mention, many therapists believe that using a checklist or intake form will make the client believe that you are inadequate and must use such aids as a crutch (1980, pg. 153). Others worry that using lists and other notes seems impersonal and the client may feel dehumanized. Thankfully, this is generally not the case, and using a checklist effectively can actually give the client the perception that you are professional and efficient (Vriend & Kottler, 1980, pg. 154). These first few minutes are key to explaining to the client what they can expect out of your sessions and to get necessary information that will allow you to help them in the most targeted and effective ways possible. First impressions are important whether we'd like to admit it or not, and this initial step can either begin to build a close therapeutic relationship or, on the other hand, may instill doubts about getting the help they need in the client's mind.
Reference:
Vriend, J. V. & Kottler, J. A. (1980) Initial Interview Checklist Increases Counselor Effectiveness. Canadian Journal of Counseling and Psychotherapy, 14 (3). Retrieved from http://cjc-rcc.ucalgary.ca/cjc/index.php/rcc/article/viewFile/2027/1874
NEW CLIENT INTAKE FORM
GENERAL INFORMATION
Full Name_____________________________________________________
Date of Birth___________________________
Age________________
Gender________________
Ethnicity______________________
PSYCHOTHERAPY HISTORY
Have you had previous psychotherapy?
YES or NO
If Yes, list the approximate dates you began and ended your previous psychotherapy
______________________________________________________________
What are you current mental health symptoms and concerns?
__________________________________________________________________
__________________________________________________________________
Are you currently taking prescribed psychiatric medication (antidepressants, anti-anxiety medications, others) to address these concerns? YES or NO
If YES, please list: ______________________________________________________
Have you had suicidal thoughts in the past two weeks?
YES or NO
If YES, how often?____________________________
CLINICAL HISTORY
Please list any persistent physical symptoms or health concerns (e.g. headaches, chronic pain, stomach cramps, fatigue, etc.: ______________________________________________________________
Are you currently on medication to manage a physical health concern? If yes, please list: _________________________________________________________________
____________________________________________________________________
Are you having any problems sleeping? YES or NO
How many hours of sleep do you think you get, on average, each day?___________
How many times per week do you exercise? ______________
Are you having any difficulty with appetite or eating habits? YES or NO
If YES, please explain _______________________________________________________________________________________________________________________________________________________________________________________________________________
How many alcoholic drinks do you have in a typical week?
____________________________________________________________________
How often do you engage in recreational drug use? NEVER, RARELY, SOMETIMES, OFTEN
What is your current relationship status?
_________________________________
On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship? _____________________________
Who do you currently live with?
_________________________________
On a scale of 1-10 (10 being the highest quality), how would you rate your current living situation? ______________________________
In the last year, have you experienced any significant life changes or stressors? If yes, please explain: ________________________________________________________
EMPLOYMENT INFORMATION
Are you currently employed? YES or NO
If YES, name of current employer___________________________
Title or position________________________________
Are you happy with your current position? __________________________
Please list any work-related stressors, if any __________________________________
SPIRITUAL INFORMATION
Do you consider yourself to be religious? YES or NO
If YES, what is your religion? ____________________________
If NO, do you consider yourself to be spiritual? YES or NO
FAMILY MENTAL HEALTH HISTORY
Has anyone in your family ever had symptoms of, or been treated for, a mental health disorder such as depression, bipolar disorder, anxiety, substance abuse, etc? YES or NO
If YES, please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXPECTATIONS
What do you hope to get out of therapy?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have anything else you'd like to add?
________________________________________________________________________________________________________________________________________________