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Unformatted text preview: [ FORM 33 —Use the top of this page for your letterhead.] Intake Interview Questions and Guide Client’s name: Date: Interviewer’s initials: q OK to thank referrer? q Yes q No q Entered into phone book q Entered into birthday book Introductory questions 1. Who suggested that you come to see me? Referral code: 2. What is the problem, in your own words? How do you see the situation? a. Symptoms—frequency, duration, intensity, latency, recurrence, course; distress caused. b. Change efforts. c. Why help is being sought now —precipitants, stressors, consequences; contexts, relevant history; needs, goals, strengths.) Essential information 3. Previous psychological episodes, treaters, and treatments. a. For what? b. Where/by whom? c. Treatment? d. When (from–to)? e. Outcome? f. Satisfaction/difficulties? (Especially follow up any hints of problems/abuse by therapists—e.g., dual relation- ships, sexual intimacies, litigation.) g. Release(s) for records signed?...
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- Spring '10
- partner, MD, Edward L. Zuckerman