First, the intake process consists of both the intake form and the initial session. Let’s examine the intake form. Usually it is best to have the client complete an intake form prior to the first session so that important information about the client is gathered and is kept on file. The counselor may want to consider how much to ask on this form as well as what most people may be comfortable sharing.
Whatever is not asked on the form (or filled out on the form), will need to be asked by the counselor in the intake session. In terms of the intake form, it is helpful to see, in the client’s own words, some of their history, their current situation and their counseling goals. Basic information all intake forms should contain are:
- Name of client
- Address of client and if the counselor may mail information to this address
- Phone number(s) of client and if the counselor may either leave a message or text the numbers(s)
- Is it an in-office visit, or online counseling?
- Email address for the client and if the counselor can send a message to the address
- Insurance information (their insurance, subscriber/group number, and their co-pay)
- Birthdate of client
- Referral source (i.e., how did the client find out about you?)
- Contact information for a person (i.e., name and phone number) is case there is an emergency associated with the client (for example, if the client becomes actively suicidal)
- Medical history as well as current medical problems; also ask about medical hospitalizations
- Current medications and amount taken each day; also obtain the name of the doctor who is providing medication management for the client and the doctor’s phone number
- Mental health history which includes questions about former mental health providers, any prior medical hospitalizations, and any suicide attempts
- Family members with a mental health history and ask for diagnosis (if known to client)
- Substance abuse history and any former treatment for substance abuse as well as any former or current issues with DUI or drug-related charges; also ask about current substance use
- History of abuse or trauma (i.e., physical, emotional, mental or sexual)
- Any current life transitions/issues the counselor should be aware of Specific behavioral, mental or physical symptoms related to depression or anxiety experienced in the last 30 days (i.e., upset stomach, feeling restless, feeling guilty, isolating from others, etc.)
- Current use of social media and time spent on Internet, Facebook or other forms of social media; also ask the client’s preferred mode of communication (texting, phone or in person), and ask if their use of social media is impacting any of their relationships
- Reason client is seeking counseling
- Goals for counseling and what the client would like to accomplish or see change as a result of counseling
Ask the client to complete the intake form prior to the initial session and to bring it in with them. Although it may be helpful to receive the intake form before the client actually comes in for the first meeting, keep in mind HIPPA regulations and confidential/privacy concerns. Email is not a secure form of communication, so this may not be a safe option for clients to use to share the intake form before the first counseling appointment. If a fax machine is available and confidentiality can be assured, having the client fax the form may be an option.
Also be sure to note the non-verbal behaviors your client exhibits during their initial discussion with you as this needs to be noted as well as monitored in future sessions. In terms of other questions to ask, it is helpful to have knowledge of the following:
- Client’s level of education
- Client’s school and/or employment status
- If client is going to school, where and what grade/level
- If client is working, where and job title/brief description
- Background information regarding client’s education (i.e., did client switch schools a lot, like learning?) and client’s work history (has client held a lot of jobs, been in the same one for a number of years?)
- Client’s relationship status as well as relationship history (i.e., formerly married)
- Client’s religious affiliation
- What it was like for client growing up in terms of family structure, relationship with siblings, parents/guardians approach to discipline
- Information about client’s culture in terms of what client and family value, traditions, beliefs
- Client’s greatest successes and biggest challenges
- What makes the client feel happy, calm, peaceful
- What makes the client frustrated, angry and hurt
- Have the client verbalize their goals for counseling
Too often in this day and age people are in a hurry to “get to the point” and rush to a solution. The intake process helps the therapist slow down the client, assists both the counselor and the client with obtaining a clear focus on past and present concerns, and it informs the counselor as to the direction to take in the counseling process.
Do not underestimate the importance of the intake process! It needs time, attention and details to make the therapy be a process that is effective and goal-directed.
Dr. Rhonda Sutton (Email) is a licensed counselor and a licensed counseling supervisor in Raleigh, North Carolina. She is the owner of InnerSights Counseling and Consultation, Inc. where she guides both clients and counselors-in-training in their professional and personal development. Her mission is to assist others in finding their own unique ways of leading productive and fulfilling lives. She specializes in couples counseling, trauma, crisis and life transitions and also serves as “the counselor’s counselor” in terms of supervision, mentoring, support and advice. Dr. Sutton is also president of STEP Notes, Inc., an e-tool that provides counselors a secure and systematic way to take progress notes. *Her intake forms are online and any information from it may be used by other counselors for their own intake forms.