Intake Interview Sample
The following questions may help me to better assist you in the Intake process
Intake Interview Questions
Name:
Date of Birth:
Age:
Female _____ Male_____
Mailing Address (street, city, state, zip code)
Phone:
Do you know sources of support and help available to you locally after you complete this
program? (Counselors, support groups, supervision, etc) Yes_____ No_____
If yes, list source and how often you use it (as part of your aftercare process, you may be asked
to make some choices using these resources).
EMERGENCY CONTACT INFORMATION:
Please give a name and phone number(s) or a person we could reach in case of an emergency
while you are attending our workshop:
Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
CHILDHOOD/ADOLESCENCE:
What were CHILDHOOD ages 1-13 were like: Happy____Unhappy____Other_____
Describe:
Any problems in school? Yes ____ No ____
If yes, please describe:
Get along with classmates? Yes ____ No ____
If yes, please describe:
Have many friends? _____________
Free or leisure time was mostly spent:
What were ADOLESCENT ages 13-18 were like: Happy___Unhappy___Other_____
Describe:
Any problems in school?
Yes ____ No ____ If yes, please describe:
Get along with classmates?
Yes ____ No ____ If yes, please describe:
Have many friends? _____________
Free or leisure time was mostly spent:
Describe any particular event or person that had a significant effect on your life:
MARITAL AND FAMILY CIRCUMSTANCES:
Current Relationship Status:
Single___ Married___Divorced___Separated___Widowed___
How many committed relationships have you been in? ___
First_______ Your Age_____
Second____ Your Age_____
Third______ Your Age_____
If applicable, reason for divorce (include divorce dates)
First:
Second:
Third:
Quality of relationship with your present partner:
ACTIVITIES AND SOCIAL INTERESTS:
I have _____ few ____ many friends. The quality of my relationships with friends is:
I enjoy group settings:
Yes ____ No ____. If no, please explain:
Please list the clubs or organizations that you belong to:
Please list games or sports you are most interested in
Please list creative interests:
How much are you involved in any of the activities listed above? Explain:
TREATMENT HISTORY:
Do you currently have one of these chemical dependencies?
How often do you use the
following?
Type:
Yes
No
How often to you use these per week?
Nicotine
Alcohol
Over-the-Counter
Drugs
Other Drugs
Have you ever been treated for chemical dependency?
Yes____ No ____
If yes, please provide the following:
Where:
When:
Length of
Treatment:
Reason
(eg, alcohol,
drugs, etc):
If more than three, please use back of this page.
Have you ever had psychiatric, marriage, codependency, eating disorder, or any other type of
counseling?
Yes __ No __
Counselor Type:
When:
Length of
Treatment:
For:
If more than three, please use back of this page.
How much concern do you have about yourself regarding the following:
What:
Extreme
Periodic
Not At All
Overeating
Under Eating or
Dieting
Vomiting
Binge Eating
What:
Extreme
Periodic
Not At All
Excessive Exercise
Weight or Body
Your Alcohol Use
Your Drug Use
Sexual Thoughts/
Behaviors
Caretaking Behaviors
What:
Extreme
Periodic
Not At All
Gambling
Financial Spending
Nicotine Use
Working/Busyness
Perfectionism
Illness/Physical Health
Professional Burnout
Please write any additional comments about your answers.
FEELINGS, EMOTIONS, AND EVALUATIONS:
On the following scale, please rate with an X your present performance in the areas indicated
on the left.
What:
Very Poor
(Many
Problems)
Average
Very Good
(Few, If
Any, Problems)
Physical
Emotional
Spiritual
Job
Family
Financial
Social
Legal
Self-worth
How do you picture yourself?
(Describe yourself in your own words.)
What are your strengths?
What are your weaknesses?
Do you have fears or anxieties about anything?
Yes_____ No _____.
If yes, please explain:
What losses have you experienced?
Have you ever had:
What:
Yes No Drug/Alcohol
Related:
When:
Suicide Thoughts
Suicide Plans
Suicide Attempts
Please describe any yes answers:
Do you currently have any physical limitations or medical conditions? Yes ____ No ____
If yes, please explain:
Do you have any special dietary needs?
Yes ____ No ____
If yes, please explain:
Please list any and all medications (prescription or non-prescription) including dosages and
reason taken (continue on the back if you need more space):
Medication: Prescribed for: Dosages:
What would you like to change in your life?
How might this Interview or workshop help you?
The following questions may help me to better assist you in the Intake process
Intake Interview Questions
Name:
Date of Birth:
Age:
Female _____ Male_____
Mailing Address (street, city, state, zip code)
Phone:
Do you know sources of support and help available to you locally after you complete this
program? (Counselors, support groups, supervision, etc) Yes_____ No_____
If yes, list source and how often you use it (as part of your aftercare process, you may be asked
to make some choices using these resources).
EMERGENCY CONTACT INFORMATION:
Please give a name and phone number(s) or a person we could reach in case of an emergency
while you are attending our workshop:
Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
CHILDHOOD/ADOLESCENCE:
What were CHILDHOOD ages 1-13 were like: Happy____Unhappy____Other_____
Describe:
Any problems in school? Yes ____ No ____
If yes, please describe:
Get along with classmates? Yes ____ No ____
If yes, please describe:
Have many friends? _____________
Free or leisure time was mostly spent:
What were ADOLESCENT ages 13-18 were like: Happy___Unhappy___Other_____
Describe:
Any problems in school?
Yes ____ No ____ If yes, please describe:
Get along with classmates?
Yes ____ No ____ If yes, please describe:
Have many friends? _____________
Free or leisure time was mostly spent:
Describe any particular event or person that had a significant effect on your life:
MARITAL AND FAMILY CIRCUMSTANCES:
Current Relationship Status:
Single___ Married___Divorced___Separated___Widowed___
How many committed relationships have you been in? ___
First_______ Your Age_____
Second____ Your Age_____
Third______ Your Age_____
If applicable, reason for divorce (include divorce dates)
First:
Second:
Third:
Quality of relationship with your present partner:
ACTIVITIES AND SOCIAL INTERESTS:
I have _____ few ____ many friends. The quality of my relationships with friends is:
I enjoy group settings:
Yes ____ No ____. If no, please explain:
Please list the clubs or organizations that you belong to:
Please list games or sports you are most interested in
Please list creative interests:
How much are you involved in any of the activities listed above? Explain:
TREATMENT HISTORY:
Do you currently have one of these chemical dependencies?
How often do you use the
following?
Type:
Yes
No
How often to you use these per week?
Nicotine
Alcohol
Over-the-Counter
Drugs
Other Drugs
Have you ever been treated for chemical dependency?
Yes____ No ____
If yes, please provide the following:
Where:
When:
Length of
Treatment:
Reason
(eg, alcohol,
drugs, etc):
If more than three, please use back of this page.
Have you ever had psychiatric, marriage, codependency, eating disorder, or any other type of
counseling?
Yes __ No __
Counselor Type:
When:
Length of
Treatment:
For:
If more than three, please use back of this page.
How much concern do you have about yourself regarding the following:
What:
Extreme
Periodic
Not At All
Overeating
Under Eating or
Dieting
Vomiting
Binge Eating
What:
Extreme
Periodic
Not At All
Excessive Exercise
Weight or Body
Your Alcohol Use
Your Drug Use
Sexual Thoughts/
Behaviors
Caretaking Behaviors
What:
Extreme
Periodic
Not At All
Gambling
Financial Spending
Nicotine Use
Working/Busyness
Perfectionism
Illness/Physical Health
Professional Burnout
Please write any additional comments about your answers.
FEELINGS, EMOTIONS, AND EVALUATIONS:
On the following scale, please rate with an X your present performance in the areas indicated
on the left.
What:
Very Poor
(Many
Problems)
Average
Very Good
(Few, If
Any, Problems)
Physical
Emotional
Spiritual
Job
Family
Financial
Social
Legal
Self-worth
How do you picture yourself?
(Describe yourself in your own words.)
What are your strengths?
What are your weaknesses?
Do you have fears or anxieties about anything?
Yes_____ No _____.
If yes, please explain:
What losses have you experienced?
Have you ever had:
What:
Yes No Drug/Alcohol
Related:
When:
Suicide Thoughts
Suicide Plans
Suicide Attempts
Please describe any yes answers:
Do you currently have any physical limitations or medical conditions? Yes ____ No ____
If yes, please explain:
Do you have any special dietary needs?
Yes ____ No ____
If yes, please explain:
Please list any and all medications (prescription or non-prescription) including dosages and
reason taken (continue on the back if you need more space):
Medication: Prescribed for: Dosages:
What would you like to change in your life?
How might this Interview or workshop help you?