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
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
    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
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

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
D. Do you have any serious medical
    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
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
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
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,
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
Note level of sensorial: memory,
consciousness, orientation, ability to
communicate, attention span, information
Note judgment: Make rational decisions,
understand the consequences of behavior
and take responsibility for actions.

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