INTAKE INTERVIEW FORM (to be attached to their Personal Information Sheet)

Name: ___________________________________________________________________________ Nickname: Technology:

Last Name Given Name Middle Name

1. Have you consulted a Psychiatrist/ Psychologist/ Counselor before? If yes, when? _________________________________________

2. How long and how many sessions?_______________________________________________________________________________________________

3. For what reason? __________________________________________________________________________________________________________________

4. What can you say about your classmates and teachers? _______________________________________________________

5. What are the subjects you like least? Why? _________________________________________________________________

6. What would you like to change at home and in your family? Why? ______________________________________________

___________________________________________________________________________________________________

7. Do you have friends here in school? At home? What do you usually do together? __________________________________

____________________________________________________________________________________________________

8. What are your strengths-talents, skills, interests, positive attitudes, etc.? _________________________________________

____________________________________________________________________________________________________

9. What do you think are your weaknesses – fear, difficulties, problems, negative attitudes etc.? ________________________

____________________________________________________________________________________________________

10. What are your plans after high school? What are you doing to achieve your plans? _________________________________

____________________________________________________________________________________________________

11. If you will be given a chance to correct one mistake you did in the past, what would that be? Why?____________________

____________________________________________________________________________________________________

12. What significant problems affect you the most that you would like to share? ______________________________________

____________________________________________________________________________________________________

13. Who would you like to approach to discuss your problem? Why? _______________________________________________

____________________________________________________________________________________________________

VALUES FORMATOR’S ASSESSMENT

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Date of In-take Interview ________________________________________________
Values Formator Name & Signature _______________________________________
Note: All information stated above will be kept confidential. Page. 1