INTAKE ASSESSMENT FORM Page 1

Intake Assessment Form:

Demographics:
Client name:

Age:

Preferred Pronouns:

Gender identification:
[ hint: always as the client what gender do they identify with]

What is your current address?:

[ hint: full address including city and state]

Any legal involvement?:

Past information:
Any prior diagnosis in the past? If so,
what?:

Have you had any recent psychiatric

hospitalizations?:

Have you been in any outpatient

programs for substance abuse or mental
health?:
[hint:list names if possible]

Are you currently on any medication?:

Are you actively taking these

medications?:

Present information:
What brings you to counseling [hint: just a brief description]:?
INTAKE ASSESSMENT FORM Page 2

Risk assessment
Have you experienced suicidal ideation
in the last two weeks?:
(If so, when?)

Do you have suicidal ideation (thoughts)

with a Plan?:

(If yes) - Details

1. What is the plan?

2. If you have a plan- do you have
reasonable means?
3. Have you started preparations?
Did you ever prepare?
4. For how long have you had the
plan?

(If yes) - Details

● Have you been able to resist
carrying this out?
● What has prevented you from
going forward?

❖ Counselor Script if YES to ANY Question : It is important that you speak about this. I am going
to provide you with National suicide hotline number. You can call and text anytime
800-273-8255.

❖ Counselor Script if NO to ALL Question: Thank you so much for your time and sharing this
information with me.
INTAKE ASSESSMENT FORM Page 3

Hearing Voices:
Have you been hearing any voices or
seeing anything in the last two weeks?:

(if yes)- Details

For the client

Do you have any questions?

❖ Counselor Script: I will relay all the information discussed today to Sadie, and we will
reach out to you shortly if it seems like a good fit to go forward with setting up a session.

Guidance for the Intern Counselors: This is the guideline to follow for intakes. Please
obviously take down notes outside of this form, as needed- but the questions listed are
important aspects to cover on the phone. Any questions that a client have that you don’t
know the answer to, you can write them down and let them know that you’ll forward to
me and I can reach back out to them. Really you’re just gathering all the information and
writing it up so I can go over it and make sure they would be a good fit for private
practice. Any suicidal ideation at all, even without a plan, provide them with the hotline
number and document that you provided it. Any questions you have as always let me
know!

Intern Counselor’s name:

Additional notes/ Concerns: