NAME:
ADDRESS:
DATE OF BIRTH:
PHONE: HOME:
UNM DEPARTMENT OF PSYCHOLOGY CLINIC
INTAKE OUTLINE AND REPORT
ID NUMBER:
WORK:
INTAKE DATE:
IDENTIFYING INFORMATION AND REFERRAL STATEMENT
1.
Include description of client’s (individual, couple, family, etc.) age, occupation, marital status and any other significant identifying information such as previous treatment at the Psychology Clinic (e.g., Mrs. X. is a 30 year old, single parent of three children, who works as a bookkeeper. Had previously been seen at the Psychology Clinic for one session. See Intake 12/07/79).
2.
Indicate the referral source, such as self-referral, referral by a physician, or social agency, and if there was a specific reason for the referral (e.g., Mrs. X. was referred to the Psychology Clinic by the Family Resource Center because of alleged neglect of her children).
PRESENTING COMPLAINT:
State briefly what is the most distressing at this time and use the client’s own words whenever possible using quotes. Indicate what kind of treatment they desire or expect, and what results they hope for (e.g., Mrs. X. would want her boyfriend involved in treatment, though he reportedly refuses to come in; Mrs. X. hopes to “get along better with him” and “take better care of my children.”).
HISTORY OF PRESENTING COMPLAINT:
Describe in chronological order (and with dates) the onset and development of the presenting complaint and how it is manifested.
(a) Onset – when the problem began to affect or interfere with the client’s daily living or became manifest to those around him.
(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.) and severity of stressors (see DSM IV, Axis IV).
(c) Note the client’s highest level or adaptive functioning the past year (12 Mon. –
See DSM IV, Axis V).

(d) Previous conditions, psychiatric hospitalizations and/or treatment which were similar to or the same as the presenting complaint (this information is often asked on insurance claim forms).
MEDICAL: Brief and mentioned if applicable. Note special medical problems present and any substance abuse. List current medications.
PERSONAL HISTORY: (Only if applicable) If personal history is not utilized, significant events or changes may be documented in
Therapist Notes, Transfer Summary, or Closing Summary,
This should briefly include any relevant occurrence (developed chronologically) and can use the following headings as a guide:
(a) Birth and Infancy: Were there any difficulties or special circumstances
(medical, adoption, frequent moves, etc.)
(b) Childhood: Overall adjustment and relationships to peers as well as academic performance (e.g., did above-average work in school and reported positive peer relationships).
(c) Adolescence: Further development including any behavioral changes, family circumstances, peer adjustment, education, and relationships with the opposite sex.
(d) History up to time of presenting complaint including vocational information, dating/sexual experiences, and marital relationship(s) if applicable. Note present living arrangement and significant socio-economic circumstances or influences.
FAMILY CONSTELLATION:
List significant persons in client’s environment, their geographic location, and quality of relationship (e.g., Mr. B., brother, age 33, lives in Albuquerque, single, and unemployed – relationship with Mrs. X. is described as conflictual as he has a long history of alcohol abuse and “won’t help me much less himself”).
CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:
Include (1) pertinent dynamic factors in the development of the presenting complaint, taking into account psychological aspects of the client’s life (e.g., family; employment, etc.), (2) appraisal of insight and motivation for treatment, and (3) level of functioning or impairment, including the client’s own strengths and resources.
Areas of functioning and/or impairment should focus on: (1) symptomatology, (2) productivity (employment; activities of daily living), (3) capacity for pleasurable experiences (hobbies; entertainment), (4) interpersonal relationships, (5) capacity to

handle ordinary conflicts and stresses. Assess and record whether impairment or reactions in these areas are mild, moderate or severe.
Note any significant information which might mean the client is “at risk” (suicidal ideation, homicidal ideation, etc.).
[Where applicable briefly note and/or assess defenses, affect, behavior, personality style, traits, and patterns. In evaluating the client, take into consideration the mental status examination.]
TENTATIVE DIAGNOSIS:
(1) According to DSM IV, or (2) Dynamic formulation with clinical features, or (3)
Reason for contact with the agency. (DSM IV V codes may be utilized.)
INITIAL TREATMENT RECOMMENDATIONS:
(a) State type of treatment utilized (e.g., crisis, insight-oriented, supportive, behavioral, psychotherapy, etc.), the treatment modality (e.g., estimated length of treatment, changes in modality, etc.). Include designation of the primary therapist(s) (e.g., Will be seen by the undersigned and Ms. Z,
MSW in group therapy).
(b) Treatment focus and/or goals with specific reference to the client’s
“reason for seeking treatment.”
(e.g., Initial treatment recommendation is individual psychotherapy on a once weekly basis. Therapy will focus on Mrs. S.’s presenting concerns around her relationship with boyfriend and child management issues. Couple treatment is possible in the future, but boyfriend presently refuses to attend sessions. Will work on symptom relief (early morning wakening) and increasing her ability for pleasurable experiences, etc.).
FINANCIAL INFORMATION:
Brief description of financial status (monthly income and financial obligations), (if relevant), means of payment (weekly or any use of insurance).