Intake or intake interview
Definition: The first meeting with a client, in which the clinician gathers information on the client's concerns and problems. Typically the intake is also used to gather background information on the person's life and problems.
Different therapist take different approaches to intakes, and over time each one develops a unique style. Some prefer a fairly structured interview in which they ask standard questions; others prefer to let the client talk and see where the conversation takes them.
At the beginning of any intake, the therapist is required to tell the client several things, including:
- The limits of confidentiality, i.e. that if the client tells the therapist that she is planning to hurt herself or someone else, or that she knows of a child or elder who is being abused. Despite many people's beliefs, a therapist does not have to report drug abuse, infidelity, or other secrets unless they are putting someone in immediate danger. There has been considerable controversy over whether the admission that someone who has not told a sexual partner that he is HIV positive falls under a therapist's duty to warn someone who is in danger due to a client's actions or potential actions.
- If she is in training and under the supervision of another (licensed!) clinician. She must also let the client know who her supervisor is, and the client has the right to meet that supervisor if she wants to.
- If she is video or audio taping the session and how the electronic files will be safeguarded or how long it will be before they are erased. This is fairly common in situations where the therapist is still in training.
Topics covered in the intake can include:
- Behavioral observations (does the person arrive on time, is s/he appropriately dressed, etc.)
- Family history
- Relationship and sexual history (if relevant)
- Occupational or school history (depends on setting)
- Medical history (ranges from hospitalizations to chronic conditions like asthma or arthritis)
- Drug and alcohol use and whether there have been any problems associated with use (e.g. blackouts, fights, in trouble with authorities)
- Stressors the person is dealing with, especially ones that are long-term, like relationship, financial, or housing problems
- Hobbies or interests
- Religious or spiritual beliefs (if relevant)
Some therapists write down statements that stand out to them as the client speaks so they can quote them in the intake. This is a nice way to capture the "flavor" (not a psychological term) of a client's presentation. Though diagnostic impressions are a part of an intake, they are kept at the bottom of the report; the rest is supposed to be a journalistic, objective report as you understand it from the client's words.
A supervisor once told me that if someone uses a metaphor that is clearly not a cliche, it's an extremely good indicator of the client's experience. For example, if someone is surprised, he'll often say something like, "I felt like I got hit with a brick." That's a perfectly legitimate description most of us have probably used at some point. But "I felt like she hit me with a water balloon full of ice water" really helps you understand that person's unique experience. It's interesting to me how few cliches people use in therapy if you really listen to them and encourage them to share their experiences.
Sample Intake Report
This writeup is not for a real person. It was written for a character in an old scifi anime series called Gatchaman. 