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Intake Forms

This intake assessment document contains sections for collecting a client's personal information, referral reason, medical and psychological history, family history, neurovegetative signs, relationships, occupational information, suicide assessment, risk level, developmental history, genetic issues, substance use, strengths, and a mental state exam. The psychologist will use this document to evaluate the client's presenting issues and determine appropriate treatment.

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maddysen
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79 views2 pages

Intake Forms

This intake assessment document contains sections for collecting a client's personal information, referral reason, medical and psychological history, family history, neurovegetative signs, relationships, occupational information, suicide assessment, risk level, developmental history, genetic issues, substance use, strengths, and a mental state exam. The psychologist will use this document to evaluate the client's presenting issues and determine appropriate treatment.

Uploaded by

maddysen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Name: Referred by:

Date of intake assessment: Date of referral:


Psychologist: Supervisor:
Notes:  Referral Reason
 History
- Onset
- Recent events
 Previous
diagnosis/treatment
 Family psyc history
 Medical history
- Gen pract.
- Medications
 Neurovegetative Signs
- Sleep
- Weight
- Appetite
- Energy
- Motivation
- Mood
- Libido
- Short term
memory
 Genogram
 Relationships including
family
 Parental history
 Occupation, education,
income
 Suicide assessment
- Risks
- Protective fac.
- Did you have
any self-harm
thoughts?
 Risk level
 Developmental
history/major
milestones
 Genetic issues
 Drug/alcohol use
 Strengths and
resources
 Mental State Exam
- Appearance
- Behaviour
- Relationship
with examiner
- Affect and
mood
- Thought
processes
- Thought
content
- Perceptual
disturbances
- Insight and
judgement

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