MENTAL HEALTH INTAKE INTERVIEW You are a person under stress (trying to do too much at one time). You have come to a counselor for stress related symptoms and are asked the following questions: INTAKE QUESTIONS RESPONSES I. Presenting Problem A. What brought you to see me today? B. How do you think your stress came about? C. What kind of stress symptoms do you have? (onset, duration & frequency) D. What makes symptoms worse/better? E. What effect has this had on your life? What changes have you noticed in yourself? II. Medical History Focus on history of chronic illnesses, medications, and conditions that may cause psychiatric symptoms (anxiety, depression, psychosis etc) III. Family History A. Genogram of family. B. Marital status. Ask client how things are going with the family at home. Ask if anyone in the family is having problems that are worrying the client. C. How does your family get along as a whole? If you were to describe your family in one word, what would that be? If you could pick a symbol for each of your family members, what would they be? D. Who do you feel closest to in the family? Why? Least closest? Why? E. What is your role in the family? Ask about household, bills, work, car, etc. F. How do you solve family conflicts? Give an example. G. How would you describe your self as a child? What is the most significant memory from your childhood? Adolescence? H. Briefly describe your relationship with your significant other. I. How do you seek intimacy from each other? J. Do either of your have any complaints concerning sexual relationship satisfaction? K. How do you deal with conflict? L. How would you rate the degree of understanding of problems and support from your partner? IV. Previous mental health experiences A. Have you ever been hospitalized or received help in the past? ( onset, frequency, and duration of problem) B. Was it helpful? What type of treatment and follow-up was involved? C. What type of medication are you on now? D. Do you have any serious medical problems? V. Occupation and Social history A. Do you have any problems with your present job? B. What are your major responsibilities at home? Have you been able to continue these responsibilities? C. Do you have any financial problems or concerns? D. Tell me about your friends and social activities? How would you describe your relationship with your friends? E. Who would you turn to if you were in trouble? Do you feel you need someone to turn to now? F. What kinds of things give you comfort and peace of mind? Will those things be helpful to you now? G. What do you think you need that would help you with your problem? H. What are your current stressors and coping mechanisms? VI. Trauma History A. Do you have any history of being hit or harmed by anyone? Were you ever hurt by anyone as a child? VII. Affective and behavioral status A. How would you generally describe your mood? B. What is your general mood at home? labile, depressed, angry, sad, flat? When do you feel worse? Better VIII. Additional Mental Status Data Note general appearance: Dress, grooming, hygiene, cosmetics, apparent age, and facial expression. Note behavior and activity: Hypoactivity or hyperactivity, rigid, relaxed, restless or agitated, motor movements, gait and coordination, facial grimacing, gestures, mannerisms, passive, combative, or bizarre. Note client’s attitude: Interactions with the interviewer (cooperative, resistive, friendly, hostile or ingratiating). Note characteristics of speech: Quantity: poverty of speech, poverty of content, voluminous. Quality: articulate, congruent, monotonous, talkative, repetitious, spontaneous, circumlocutory, confabulations, tangential, pressured, stereotypical Note alterations in perceptions: Hallucinations, illusions, depersonalization, serialization, or distortions. Note form and content of thoughts: logical, loose associations, flight of ideas, autistic, blocking, broadcasting, neologisms, word salad, obsessions, ruminations, or delusions. Note level of sensorial: memory, consciousness, orientation, ability to communicate, attention span, information processing. Note judgment: Make rational decisions, understand the consequences of behavior and take responsibility for actions.
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