INTAKE INTERVIEW
Institution:
Student’s name:
Date:
AGENCY NAME
Gentle Blooming Clinic
MISSION STATEMENT
To provide best-practice psychology services in a prudent and supportive environment that nurtures collaborative relationships and pursues to realize the best viable outcomes for all clients and associates.
POPULATION SERVED
Our agency is dedicated to serving people with emotional difficulties, including stress at work, problems with family relationships, marital difficulties and all emotions that clients find personally significant.
ELIGIBILITY REQUIREMENTS
- Our agency requires significant evidence of emotional disturbance in thoughts, behaviours and feelings, which cause substantial impairment to the client’s life before intake.
- Family/employer/spouse recommendation.
DEMOGRAPHIC INFORMATION
Name: Rafe Anderson
Age: 29
Address: (601) 645-3414
66 Old Hill Rd
Westport, Connecticut (CT), 48462
Phone Number: (203) 423-4694
REFERRAL SOURCE AND REASON FOR REFERRAL
Referral Source: Leaning In Clinic
Reason for referral: Due to prolonged emotional stress with no practical outcome and conflict of interests between counsellor and client affecting the ability to provide therapy.
INFORMED CONSENT
COUNSELLOR -CLIENT SERVICE AGREEMENT
I understand that my personal information disclosed during my sessions is generally confidential, and I have the right to withdraw my consent in the course of my care at any time. I understand there are possible risks and benefits associated with any form of therapy; despite my counsellor’s efforts and mine, my condition may not improve, and in some cases, it may get worse. I understand my personal information may be shared with other parties for scheduling and billing purposes. I understand that my express consent is required to redirect my personal information to a third party, and I have the right to access my medical information and records with the laws referencing the state of my legal residence. Therefore, by signing this agreement, I acknowledge that I have read and understood the policies and procedures of Gentle Blooming Clinic.
Client’s signature ______________________________ Date __________
Counsellor’s signature _____________________________ Date __________
STRENGTHS ASSESSMENT
- How do you see the positive side of things?
- How optimistic are you?
- Can you tell when you feel stressed?
- Can you tell when you are not coping well?
- Do you usually focus on solving the problem, or do you instead feel down about them and complain?
- How hopeful are you about the future?
- Do you often worry about the future?
- Do you know when you need help from others?
INTAKE SUMMARY
Workers Name: (Your Name)
Date of Contact: March 1, 2022
Date of Summary: March 15, 2022
Sources of Information during the Interview
- The client’s intake form.
- Client’s therapy history from Leaning In the clinic.
- Teleconsulting tools.
Presenting Problem
Rafe Anderson has been struggling with emotional difficulty for over two years. He struggles with feelings arising from emotional experiences and responding physiologically and behaviorally to the experiences. Anderson struggles with intense pain and anxiety after the loss of his father in a car accident, where he survived. He struggles to control anxieties related to car accidents. He can’t use a car to travel as he’s afraid the accident might happen again.
Summary of Background and Social History Related To the Problem
Anderson experienced a car accident in February 2020, which took his father’s life and left him with a massive scar on his left arm. He healed from his wounds and got discharged after four months. His struggle to accept what had happened to his father led to the emotional and psychological difficulties he experiences today. Whenever he sees any Chevrolet SUV, anxieties and flashbacks arise about the car accident since that’s the car they had an accident with. He’s not able to travel comfortably in any car due to the trauma. He has been acquiring psychological therapy from the Leaning In clinic from December 2020 until March 1 2022, until his referral to Gentle Blooming Clinic.
Diagnostic Summary Statement
From Anderson’s case, there is a need to address anxiety attacks, nervousness, confusion, delusions, sadness, compulsions, obsessions, grieve, stress, tension and thought disorganization.
Anderson’s possible solution lies within these aspects and elements; thus, they will serve as our guiding principle to treatment solutions.
Treatment Recommendations
Our agency can provide Anderson with the right services to help him overcome his emotional difficulty concerning the subjective experience. We will treat Anderson with complicated acceptance and grief since it has been persistent and intense beyond twelve months. We will use psychotherapy and medications as treatment then initiate a specific coping and support mechanism.
