Intake Assessment Christina Branco Psychotherapy 308 Wellington St, Kingston ON K7K 7A

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Brice Turner
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1 Intake Assessment Christina Branco Psychotherapy 308 Wellington St, Kingston ON K7K 7A Name: Date of Birth: Family of Origin History: (*please include yourself in this table) Family Member Father Name Age Occupation Personality Emotional Health Date: Comments (roles, dynamics, relationship ) Mother Oldest Child Next Oldest Next Oldest Youngest Child 1

table) Family Member Father Name Age Occupation Personality Emotional Health Date: Comments

2 Family History 1. Do you know if your mother had any problems with your birth? 2. Are you your parent s natural child? Where you a planned child? 3. Did your parents tell you what kind of a baby/child you were? 4. Did you learn to walk by 1 and talk by 2? Did you experience any developmental difficulties as a child? 5. Who were you closest to growing up? 6. Describe your family life a. Economically: b. Socially: 2

Did your parents tell you what kind of a baby/child you were? 4.

3 c. Culturally: d. Religion: 7. Describe your parents marriage. Were they affectionate? How did they deal with conflict? 8. Did anyone in the family or extended family become hospitalized for mental illness or emotional reasons? 9. Including yourself and your family have there been or are there currently any suicidal thoughts or attempts? ( If the clients response is yes, see Addendum ). 10. Who disciplined you? 11. What personality features do you have that your parents also have? 12. What messages about your worth and worth of others were communicated by your parents? 3

Including yourself and your family have there been or are there currently any suicidal thoughts or attempts?

4 4

5 13. List 5 things you most needed from your mother/father which you don t feel you got If you had miraculous powers to change your family and childhood experiences in any 3 ways, what would you choose?

6 Educational and Developmental History 1. What was your first day of school like? 2. How many home moves and school changes occurred during school years? 3. Did you have a group of friends during the first six grades? 4. What was your personality during your early teen years? 5. Were you supported entering into puberty? 6. Describe your relationship with peers and friends during your teenage years. 7. Describe your relationship with teachers during your teenage years. 8. What was your first date like? 6

Did you have a group of friends during the first six grades? 4. What was your personality during your early teen years? 5.

7 9. How old were you with your first sexual experience? 10. Were you ever sexually abused? 11. What is your sexual orientation or preference? 12. How old were you when you left home? Why did you leave? 13. Did you attend college or university? 14. How old were you when you first went to work? 15. Describe your relationship with bosses and co-workers. 7

How old were you when you left home? Why did you leave? 13.

8 Present Family Partner: None (never married or co-habitated) ( husband, wife, etc.) Eldest Child: None (no children) Next Child: Include in table: Step children, deaths, miscarriages, terminated pregnancies. 1. How do you feel about your present family? 2. What roles or dynamics do you see playing out? How do family members get along? 8

deaths, miscarriages, terminated pregnancies. 1.

9 Significant Family and Friends Include in list: past & current, platonic and romantic

10 Current Information 1. What is your use of cigarettes, alcohol and / or drugs? 2. Has anyone ever complained of your use or has it gotten in the way of work, family or social relationships? 3. Do you have an eating disorder? If no, have you in the past? 4. Have you had any past arrests, warrants, charges or suits against you? 5. What are some of the ways you choose to escape from feelings or problems (i.e. shopping, watching tv)? 6. Are you currently taking prescription medication? If yes, what medication and what was it prescribed for. 7. Do you have a support network or a satisfactory group of friends? 10

If no, have you in the past? 4. Have you had any past arrests, warrants, charges or suits against you? 5.

11 8. Have you been to a counselor in the past? If yes, what kind of therapy and why did you leave? 9. What are the areas of stress in your life at this time? 10. Would you describe yourself as a spiritual person? 11. What are your goals for therapy? 12. What are your expectations of the therapeutic process? 13. Is there anything of significance which you would like to add? 11

12 Addendum 1. Do you feel safe with yourself? 2. Have you thought about a method of suicide? 3. Do you live alone or do you have supportive people around you? 12

Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:

Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent