Project: Psychotherapy Initial Interview

This research project is twofold and will involve active participation and observation as well as a written report portion.

Choose a participant and conduct an in-depth biopsychosocial interview. The interview should take between 45 minutes to 1 hour and should be in the participants’ natural setting (home, school, work, etc.). Try to ask them about different moments in their day and how they are accomplishing a variety of tasks. Make sure to take notes on the behaviors that you observe in your participant.

Then, create a biopsychosocial interview report, similar to the one attached below to these directions. Do not provide any personal information (names, identification numbers, and specific incidents) on your participants that may affect their confidentiality. Your written report should be no shorter than 2 pages, but no longer than 4 pages.

Psychotherapy Initial Interview/Intake Format

 

Name:                      Date of Birth:

 

Age:            Date of Initial Evaluation:

 

Examiner:

Identifying Information & Referral Source:

Presenting Complaint and Symptoms (Tell me a little about yourself):

History of Presenting Complaint

Medical and Psychiatric History

 

Personal History/Family Background

  • Born:
  • Raised:
  • Childhood:

 

Parents

Still together?  Y   N

If divorced, age of client when parents divorced ____ who did client live with? ________

Parental Employment:

Problems in the house growing up:

Siblings:

 

Marital Status: Single ___ Married ___ Separated ___ Divorced ___

Children (ages):

Relationship W/ Children:

Children at Home:

Family History of Mental Disorders:

Family History of Alcohol & Drug:

 

Social Relationships

Social Activities:

Peer Relations:

Recreation:

Church Attendance:

Importance of Religion to the Client:

Notes on Social Relationships:

 

Education

 

High School:    Graduated:

Special Education Classes:

Retained:

Suspensions/Expulsions:

Extracurricular Activity:

 

College/University:     Graduated:

Major:

Attendance:    GPA:

Favorite/Least Favorite Classes:

Future Goals:

Notes on Education:

 

Physical Health

Current Health:

Allergies:

Medications:

Medical History

Notes on Physical Health:

 

Employment

Work History:

Were you fired from a job?

Problems with Peers/Supervisors?

Opinion of Job:

Notes on Employment:

 

Mental Health

Typical Mood:

Describe Your Personality in Three Words:

If I were to ask someone who knew you pretty well, but was not a friend, to describe you; what would that person say?

Have you ever seen or heard things that were not really there? Yes or No?

If yes, please describe the experience:

Do you have problems managing anger?

How do you deal with stress?

Mental Health History (Hospitalizations/Therapy? Who? What? When? Was it effective?)

***Note whether there is evidence of delusional material. (Do not ask this)***

Notes on Mental Health:

 

Alcohol & Drug Use

Use of Alcohol: (Frequency? Amount per Day?):

Use of Tobacco: (Frequency? Amount per Day?):

Use of Caffeine: (Frequency? Amount per Day?):

Use of Controlled Substances/Recreational Drugs & Medication:

(Frequency? Amount per Day?):

Alcohol & Drug Rehab? (Dates? Length of Stay?):

Notes on Alcohol or Drug Use:

 

Legal History

Traffic Citations:

Accidents:

Arrests/Charges:

Notes on Legal History:

 

Cultural/Individual Differences That May Impact Treatment

Clinical Descriptions, Impressions, and Observations:

Mental Status:

Tentative Diagnosis (DSM-5):

Clinical Formulation & Treatment Plan Recommendations: