Paper details I. Identifying data
A. Client’s name address, and telephone number at which the client can be reached. This information is important in the event that you must contact the client between sessions. The client’s address also give some hint about the conditions under which the client lives (example large apartment complex, students dormitory , private home, Inner- city project.) B. Age, sex, relationship status, occupation [or school class and year], those living in a household. Again, this is information that can be important. It lets you know if the client is still legally a minor, and provides a basis for understanding information that will come out in later sessions. For children, it is essential to know that what adults supports are available to the children in the home.
II. Presenting problems, both primary and secondary
It is best that these problems are presented in exactly the way the client reports them. If a problem has behavioral components, they should be recorded as well. Questions that help reveal this type of information include the following: A. How much does the problem interfere with the client’s every do functioning? B. How does the problem manifest it self? What are the thoughts, feelings, and so on, associated with it? What observable behavior is associated with it? C. How often does the problem arise, and how long has the problem existed? When did it first appear? D. Can the client identify a pattern of events that surrounds the problem? When does it occur? With whom? What happens before and following its occurrence? Can the client anticipate the onset of the problem? E. What caused the client to decide to enter counseling at this time? III. Clients current life setting
What is the background or context for the client’s daily functioning? A. How does the client spend a typical day or week? B. What social, religious, and recreational activities does the client undertake? C. What is the nature of the client’s vocational and /or educational situation? D. What special characteristics about the client- cultural, ethnic,religious, lifestyle, age, and physical or other challenges -must the client the address on and on going basis? IV. Family history
A. Father’s and mother’s ages, occupations, descriptions of their personalities, family roles relationships of each to the other to the client and other siblings. B. Names and ages of brothers and sisters, their present life situations, relationships between client and siblings. C. Is there any history of mental illness in the family? Substance abuse? Domestic violence? D. Descriptions of family stability, including number of jobs held and number or family moves ( and reasons). This information provides insights during the later sessions when issues related to clients stability and / or relationships emerge. V. Personal history A. Medical history: Include any unusual or relevant illness or injury from the prenatal period to the present. B. Educational history: Include academic progress through high school and any post high school preparation. This includes extracurricular interests and relationships with peers during schooling. C. Military service history. Did the clients name in combat? What kind of assessment did the client undergo upon return to the United States? Did the clients see action? Was that client wounded? Is there any indication of posttraumatic stress disorder(PTSD)? D. Vocational history:Where has the client work? At what type of jobs? For how long? What were their relationships with fellow workers? E. Sexual and relationship history: With what sexual orientation does the client self identify? Has sexual orientation been an issue in one’s family, cultural group, or community? What is the client’s history of committed relationships? Is the client currently in a committed relationship? Does the client have children or step children? F. What experience has the client had with counseling, and what were the client reactions? G. Alcohol and drug use: Does the client currently use alcohol or drugs? Has the client used alcohol or drugs in the past? To what extent? H. What are the client’s personal goals in life? To what extent are these complicated by the presenting problem? VI. Description of the client during the interview Here you could indicate the client’s physical appearance, including dress, posture, gestures, facial expressions, voice quality, tension; how the client seemed to relate to you in the session; the client’s readiness of response, motivation, warmth, distance, passivity, and so on. Did you observe any perceptual or sensory characteristics that intruded on the interaction? What was the general level of information, vocabulary, judgment, and obstruction abilities displayed by the client? What was the stream of thought and rate of talking? Were the client’s remarks logical? Were they connected to one another? VII. Summary and recommendations In this session, acknowledge any connections that appear to exist between the client’s statement of a problem and other information collected in this session. What type of counselor do you think would best fit this client (assuming that you are responsible only for the intake)? What is your understanding of the client’s rationale for seeking Counseling at this time? To what extent is this client an appropriate fit for the services offered at your agency? How long do you think counseling might require?
Write an intake /assessment and planning summary 6 pages double-spaced Identify a current or existing problem in the life of a friend /classmate/ co-worker /member of your family. It might be relationship conflict, a relationship issue, a financial problem, or work or school related concern. Select someone with whom you feel comfortable discussing how his/ her background and history has affected the development and maintenance of this concern.
