In this brief presentation on Intake Form
Template you will take away: The important parts and pieces of a sample
intake form assessment Learn how a robust intake form gets counseling
started off right Discover where you can download an intake
form assessment immediately Let’s take a look at the two page intake
form template on your screen: Notice that the first line item on page 1
is “Client’s stated purpose for counseling.” Here you will briefly state the reason the
client gave you when you asked the question, “What brought you here today?” You can see that there are 11 specific areas
of clinical concern plus space for other. Consider page 1 the place where you will summarize
your findings from the biospychosocial (Which incidentally is a comprehensive 5 page tool
that dovetails seamlessly with this Intake Assessment Form you’ll receive both in the
Intake Forms Tool Kit) Page 1 is like a snapshot of all the areas
of clinical concern. This is the kind of concise information you will need about your client
to begin making an accurate diagnosis and creating an appropriate treatment plan. Take Away Tip: The intake assessment consists
of 2 broad sets of data: 1.) Page one which focuses mainly on the historical
information reported to you by the client. 2.) Page 2 has to do with your professional
clinical impressions based on the client history and your professional analysis and observation. OK, let’s move on to page 2 of the Intake
Form Template Clinical Observations:
This is essentially your mental status exam where you assess mood/affect, behavior, cognitions
etc. Next you record your Clinical Impression including
the client’s insight and judgment: This is where you write out your own statement
about how the client presented to you: Include those things that are of clinical concern
and relate direct to client’s presenting problem and reason for counseling. Take away tip: Always do your best to write
in measurable and observable terms, avoiding stereotypes and opinionated statements. Keep
it concise and to the point. You are creating a professional picture/snapshot of how the
client appeared upon intake. Finally, record your diagnostic impressions This Intake form assumes you will be using
the DSM V diagnostic criteria, plus it includes a space to record defense mechanisms. Not all therapists make note of defense mechanisms
but I have found it helpful for myself and the client to identify those, since they can
play such an important role in the client’s recovery. Here’s a couple questions to consider: “How
will the diagnosis help the client” to reach their goals. Is assigning a diagnosis in the
best interest of the client. Now I’m going to show you the alternative
Intake Form in the Intake Forms Tool Kit. As you can see all is the same on the second
page except the Preliminary Diagnostic Impressions: On the “non DSM” form it simply asks for
you to identify the “primary problem” and also note whether there are substance
issues, health issues and psychosocial stressors. As well as a prompt for identifying primary
defense mechanisms. Take Away Tip: Helping the client to identify
and utilize healthy defense mechanisms can have a very significant and positive impact
on therapeutic outcome. In Summary, the intake form has 2 main categories
of information: 1. The client history
2. The therapist’s clinical observations and impressions A robust form like this one will assist you
in conducting a thorough and effective intake that will help identify the primary areas
of concern and begin to formulate the treatment plan goals and objectives. For more information on downloading this intake
form assessment as well as other tools and forms to make your job easier go to http://IntakeForms.net/
or click the link in the description below this video. For more Counseling Forms tips subscribe to
my Counseling Forms YouTube Channel NOTE: In the video I state this Intake Form
Assessment is available in the Private Practice Starter Kit. It is also included in the Intake
Forms Tool Kit.

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