PSYC6233 Initial Intake Assessment Tool
Review the Intake Template as well – you will be submitting the template as your
assignment – this current document is a guide
Patient Name (hypothetical): Age, DOB, Date of service
Chief Complaint/Concern: reason for seeking assistance in clear description and client quotes
Why is the service being sought currently: was there a particular precipitating event? was there a
mandate to attend assessment/treatment?
Current functioning (current situation): orientation to current timeline, eye contact, appearance,
gait, physical observations, insight, memory, cognition, thinking patterns (including delusions,
illusions, hallucinations), mood and affect, speech patterns, …
Symptoms: anxious, depressed, sad, angry, guilt, shame, resentful, etc.
Risk
Suicide Ideation or Action: assess for suicide thoughts, intent or plan (keep in mind in this
assignment, there is not a presentation of immediate risk but you must ask about it)
Risk considerations for others: interpersonal violence intent or plan, homicidal intent or plan,
caring for vulnerable others where abuse/neglect are a concern, broader intention to cause harm
in a public setting
Drug/Alcohol/Substance use patterns: patterns including frequency and volume, motivation for
use, situational use, etc.
Current/Past Psychological Diagnosis and/or Treatment: therapy, groups (self-help or mandated),
medications, hospitalizations
Medical History: (current/past medical history)
Medications: (current/past)
Childhood history: tell me about your childhood, growing up, etc.
Family History:
Family Mental Health History- inquire about any mental health diagnosis or treatment,
consider if there was suspected mental health history that was not diagnosed or treatment, family
history of substances, violence or suicide
Cultural, spiritual, contextual and gender identity and history: traditional, accultured, social, and
varied ways of experiencing, knowing and believing should be uncovered; meanings of
behaviours or symptoms may be unique culturally
Work History: occupational patterns and successes or challenges
Current-meaningful work or any work that is currently engaged (paid, barter, or unpaid)
Past-past work and rational for change to current role/work
Volunteer History: other work and involvement in community, successes and challenges in that
environment
Social Interaction: with whom is time spent and what are those interactions like?
Present/Past abuse: (physical, sexual, emotional, verbal)
History of Victimization or Traumatic event: date and event and follow up subsequent to the
event(s)
History of Injury: workplace or otherwise, surgery, treatment, rehabilitation, functional
capabilities
Legal: any legal concerns or issues in past or present
Stressors:
CurrentPastSupports: any support system in place (i.e., family, friends, partners, spouses, groups, culturalframeworks, spiritual, religious)
Strengths:
Effective coping strategies learned or modelled
Individuals, groups, social and spiritual connections that offer independence,
strengthening, resilience
Historical review of DSM Diagnoses: (current/past) – You do not provide diagnosis - you obtain
a diagnosis that has already been provided
Medications: any (current/past) – this does not indicate that you prescribe any medications or
supplements, you obtain information about medications/supplements that the client is currently
taking
Goals: Goals for therapy (co-constructed)
Treatment Plan/Recommendations: consideration about what will be the plan and pattern going
forward to support the client based on the information taken in (greater focus in Assignment 3),
consider recommendations for further assessment measures (i.e., SFPQ, PSI-2, DSM cross
cutting measures) related to Assignment 2 and 3
Follow-up: next appointment
Outcome from the SRS: what resonated or requires shaping based on the meeting with the
session, the approach/method, goals/topics, and relationship/rapport