INTERVIEW SCHEDULE

1. Identification data:
Name __________________

Education________________

Age____________________

Occupation_______________

Sex____________________

Martial status_____________

Address____________________________
____________________________
____________________________
Contact No. ___________________________
____________________________
2. Information related to the problem
a) Does the problem interfere with day to day activities?
Yes/No.
___________________________________________________
b) If yes, How much? ____________________________________
c) Thoughts ___________________________________________
d) Feelings_____________________________________________
e) Behavior___________________________________________
f) Since when problem began?____________________________
g) Frequency of problem_________________________________
h) Events leading to problem______________________________
i) When does problem occur?_____________________________
j) With whom does problem occur_________________________
k) What happens before & after problem occurs?
_____________________________________________
l) Reason
for
seeking
counseling?
_____________________________

3. Clients present life situation.

a) How
is
the
typical
day/week
in
the
life?
_____________________________________________________________
_____________________________________________________________
__________________________________________________________
b) Activities undertaken
Social_________________________________________________________
Religious______________________________________________________
Recreational___________________________________________________
c) Present
education
______________________________________
d) Present
situation_____________________________________

situation
vocational

4. Family Setting
a) Information about parents
Mother Name________________
Name___________________

Father

Age_______________________
Age__________________________
Occupation_________________
Occupation____________________
b) Personality
mother__________________________________________
Personality
of
____________________________________________
c) Relationships:
Between
mother
father_________________________________
Between
mother
client_________________________________

of
father

and
and

 Between
father
client___________________________________
Between
parents
siblings_______________________________
Client
siblings_______________________________________
Client
grandparent___________________________________

and
and
and
and

d) Siblings:_____________________________________________________
_
Number
siblings_____________________________________________

of

1. Their
name_____________________2._________________________
Age_____________________________________________________
Sex_____________________________________________________
Birth order________________________________________________
Education________________________________________________
Occupation_______________________________________________
__
Men: Status_______________________________________________
e) Any history of physical illness in family?Yes/No.
If
yes,
what
it_______________________________________________

was

f) Any history of mental disturbance in family? Yes/ No.

___________________________________________________________

If
yes,
what
was
it?
____________________________________________
g) Family
mobility_______________________________________________
How
many
places
family
has
lived
in?
______________________________
How
many
times
parents
have
changed
job?
_________________________
5. Personal History
a) Educational
History____________________________________________
Academic
Progress___________________________________________
Talents
shown
in
academic
career________________________________
__________________________________________________________
Other
involvements
while
in
school/college__________________________
___________________________________________________________
__________________________________________________________
Peer
relationship______________________________________________
__________________________________________________________
Relationship
with
teachers________________________________________
__________________________________________________________
b) Work experience:
Has the client had past time jobs? Yes/ No. If Yes,
Its nature______________________________________________
Duration_______________________________________________
_
Has the client held full time jobs? Yes/No. If yes,
Its
nature_______________________________________________
Duration_______________________________________________
Any
significant
achievement
during
work_______________________

_______________________________________________________
________________________________________________________
Any
significant
experience
during
work_______________________
________________________________________________________
_____________________________________________________
Relationship
with
coworkers________________________________
_____________________________________________________
______________________________________________________
c) Medical History(Since childhood to present)
Any
major
illness_____________________________________________
Injury______________________________________________________
Surgery____________________________________________________
d) Martial history
Relationship with opposite sex(partner or spouse)
_____________________________________________________________
_____________________________________________________________
___________________________________________________________
Any present or previous emotion involvements?
_____________________________________________________________
___________________________________________________________
Reasons for previous relationships breaking down?
_____________________________________________________________
_____________________________________________________________
__________________________________________________________
e) Any
previous
experience
with
counseling?
___________________________
_____________________________________________________________
__________________________________________________________
f) Drug/alcohol use.
Currently_______________________In
the
past_____________________
Extent
of
use___________________Extent
of
use____________________

g) Personal
goals
in
life___________________________________________
__________________________________________________________
h) Career
goals
in
life____________________________________________
__________________________________________________________
6. Description of client interviews:
a) Temperament_____________________________________________
__
b) Behavior/mannerism______________________________________
___
________________________________________________________
c) Body language____________________________________________
d) Facial
expressions___________________________________________
e) Postures
and
gestures_________________________________________
f) Eye contact_______________________________________________
7. Language
fluency
_____________________________________________
Logical______________________________________________________
Tone of voice________________________________________________
Speech_____________________________________________________
Summary: