As you and your cohort settle into practicum, you will hear at some point about the intake process, specifically how different sites may have different ways of approaching an intake. Department of Mental Health sites in your county may have an intake form with questions that go on for several pages. For example, the Los Angeles County Department of Mental Health Adult Intake form has nine sections, with subsection questions for each one!
However, if you find yourself in a site that allows you freedom to conduct a semi-structured intake, it may still be challenging to find the balance between having an organic session with the client while obtaining relevant information that can inform your treatment plan.
The Intake
1. Identifying Information
You will undoubtedly come across this in your academic training through vignettes, class exercises, and homework assignments. Include their age, identified sex, sexual orientation, religious/spiritual beliefs, and living situation. If you work with college students, their academic goals, major, and level of functioning may also be useful.
Your site may have an intake form the client has to fill out before seeing a therapist; that information may already be included. Asking about sexual or gender identity can seem imposing for a first session. The key is to get a feel for the client and establish a comfortable working relationship during your conversation about informed consent, emphasizing the extent of confidentiality at your site. Asking if clients are comfortable disclosing their sexual orientation after that conversation usually typically yields an answer. If not, it is important to affirm their decision and move on without drawing attention to their decision not to provide that information.
2. Presenting concerns
Beginning this section by asking, “so what brought you in to see me?” or “what can I help you with today?” establishes friendly atmosphere. Clients will usually be able to articulate some form of symptomology or another; you’ll want to get information on how often symptoms occur, their severity, a history of their symptoms (how long they’ve been experiencing them), and how it impacts their functioning. Does it get in the way of work, school, or sleep? How so? Clients will most likely disclose more than just these things, and it doesn’t hurt to ask if there’s something else you’d like for them to elaborate on!
3. Clinical observations
Take note of your client’s alertness and orientation. Outside of doing a Mini Mental Status Exam, you can gather orientation through asking four questions: their name, their location, the day of the week, and what they were doing right before they arrived or as they were arriving (in the world of emergency medicine, this is typically used to assess a client’s mental orientation when arriving on scene, where the last question is replaced with asking if they know what happened to them just now).
When explicitly asking those questions, I’ve yet to find a client who felt negatively about them. However, if you should feel the need to make it feel more organic, you can simply ask them to state their whole name to help you learn the pronunciation, ask what day of the week it is because you’re trying to fill out a form and it’s slipping your mind, ask them to clarify if they know where they are (following it up with the qualifier that you just wanted to make sure they’re here for mental health services and not something else), as well as a friendly question on how they felt and what they were doing as they were getting ready for session.
That seems like a mouthful, but as you grow more comfortable, you’ll find this process to be quite brief, assuming they do not have difficulty with any of the questions. Next, you can assess their memory simply by how they describe other sections of the intake. Their long-term memory can be intact if they’re able to recall events from their childhood or from years ago, and their recent memory can be assessed by listening to them describe events from earlier that day, or days/weeks ago. Also note their movements; are their gestures within normal, conversational bounds? Or are there a lot of animated movements, or even a noticeable lack of body movement? Body movement outside normal conversational bounds is often described as psychomotor agitation.
Listen to clients’ speech volume and speed, as well as response latency (their ability to answer a question or respond to you in a timely manner).
Thought content can be assessed by determining if their responses are appropriate for your questions and the topics, as well as if they are relevant to the intake.
Thought process can be described as linear and organized on one end, and disorganized and tangential on the other. Tangential speech starts at one point and never returns to the original prompt, and in charts and notes is often understood as a proxy for psychosis, so use “tangential” and “disorganized” with caution. Circumstantial speech may be a good descriptor for clients who answer to a question by telling stories, narratives, or hitting different, unrelated points before coming to an answer that is relevant to your queries.
Do include other noteworthy clinical observations; this is not an exhaustive list. You may include whether clients make unusual amounts of eye contact or none at all, if their speech changes when talking about certain topics, etc. As you conduct more intakes, you will undoubtedly gain proficiency in noticing behaviors that are out of the norm or not found in most of your clients.
4. Psychosocial history
Ask clients where they were born and raised, and who they lived with growing up. It may be helpful to ask them how they got along with their family/friends when they were younger, and how they do so currently (if they’re older, feel free to ask them to elaborate on how they got along with family and friends in different periods of their life).
Ask what school was like if applicable, as well as if they took any special needs or gifted courses growing up. Discuss their efforts in making friends and socializing when they were younger as well as currently, noting if there are any changes (for example, a client may have made friends easily as a child, and found it more difficult in high school onward).
Details and specifics will fill out this section more as clients discuss unique life events, such as moving to different cities, shifting family dynamics, living with various relatives, and other life events.
5. Previous mental health treatment
If clients have seen a therapist before, discuss if they found it helpful or not, and why. Ask how long they were in treatment, as well as what type of setting it was (a community mental health site, hospital, school counseling, private practice, etc.). If they have no history of mental health treatment, ask if there was anything that kept them from seeking services.
6. Substance abuse history
Ask if clients currently drink or smoke (cigarettes, vaping, tobacco, marijuana), or use any other recreational drugs. If they do, ask them to elaborate on how often and how much they use. It’s not unusual to have clients report that they drink or smoke “sometimes with friends” or something similar.
You can follow up by asking them to elaborate; how many times a month do they socially smoke, drink, or use other substances? If they do not currently use any substances but have in the past, ask how long ago, how often they used to, and when they started and stopped.
7. Health status
Inquire about any current chronic/recurring/significant medical issues, and check if they are being managed by a healthcare professional. See if they can remember their last physical or physician’s appointment. Ask if they know if any medical issues run in their family, and if anyone in their family has also experienced mental health issues.
8. Assessment
Think of this section as the part where you generate your treatment plan based on what you know, and things to consider in therapy. Based on the client’s reported symptoms, what do you think they may benefit from? For example, a client’s self-report might have you see a mix of generalized anxiety and panic, suggesting a need to cultivate calming coping skills.
Will the client benefit from cognitive reframing to address anxiety, and somatic-oriented practices such as meditation to address panic symptoms? In other words, note their problems, informed by needs and other considerations that come up during the intake.
9. Risk factors
Does the client have present or past suicidal ideation? Trying to ask clients this question can seem daunting and encroaching on their privacy, but research suggests that asking about suicidal ideation doesn’t increase the risk of suicidal behavior; on the contrary, for suicidal clients, it can lead to improvements in treatment [1]. In addition, you’ll have clients who do not present with a history of suicidal thoughts/behaviors, and they’ll answer the question candidly. I’ve found that clients are forthcoming with their past experiences with suicidal thoughts and behaviors, and the key is being able to listen to them with empathy. Asking them what was going on in their life at the time can foster dialogue that can build a more positive working relationship. Other risk factors include a history of abuse, social isolation, lack of peer/family support (real, perceived, or otherwise), drug use, and no positive coping skills. Ask them how they’ve been managing their symptoms, and what they do when they experience them. Make sure to also note positive protective factors in their life as well, such as family/peer support, pride in their job/goals/aspirations, and anything else they may perceive to be a protective factor.
10. Ethical issues
Is there anything to contraindicate treatment with you for this client, such as having multiple relationships, or severity of symptoms that may warrant a referral to a more appropriate treatment setting?
11. Treatment goals
Make sure to write out what the client wants to accomplish, using their own words, and elaborating on those goals as necessary. If a client reports wanting to get their anxiety under control, try to get a clearer picture of what they think that looks like; how would they function at work or with family? How often would they experience anxiety after seeing you for a month? Are they invested in a reduction of frequency and severity of symptoms, or do they want to try to obtain total symptom removal? This conversation leaves room for both therapist and client to collaborate on a concrete, obtainable goal.
12. Collaborative action plan
This is the section that illustrates what you and the client agreed on for treatment. This doesn’t have to be a section to describe the technical names of an intervention you decided on, but rather how those interventions were explained and may play out in therapy. A client with anxiety may collaborate with a therapist and agree on practicing body-oriented calming techniques to address panic symptoms as they occur, as well as thought logging to reframe automatic thoughts about the client’s self.
Timing
Depending on your time constraints, you may find it helpful to ask for a client’s presenting concerns near the end of the intake, before moving on to treatment goals and the collaborative action plan. Presenting concerns can lead to very thorough conversations about clinical issues. This may also organically lead into a therapy session, leaving you with little to no time to collect other information.
By saving presenting concerns for near the end, you can allow clients to discuss their presenting problems while having a natural segue into treatment goals and an action plan. However, keep in mind that this template is for a semi-structured interview. By its very nature, it’s intended to be utilized by the therapist in a way that works best for their own practice. Early in your training, you may sound very structured any time you use any form of a template or questionnaire.
As you develop in your professional training, your own clinical style will inform how you ask these questions, what you notice and want to elaborate on, and how you’ll record your observations/answers.
It’s more important to ask for feedback from a supervisor on what your site believes is more relevant for an intake and adjust accordingly. Before you know it, you’ll be able to complete a semi-structured intake with time to spare. Remember to ask the client their feelings about how the intake was for them and to assess their motivation to continue treatment.
Take those final minutes to establish some comfort and build your client’s confidence in treatment. Just as important is your confidence in your actual treatment plan. Completing a thorough intake and having enough information to inform treatment is always a great way to start therapy for the client and the therapist.
This article was originally published on October 3, 2018.
References
- Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Great article, thank you!