UNM DEPARTMENT OF PSYCHOLOGY CLINIC

INTAKE OUTLINE AND REPORT

NAME:

ID NUMBER:

ADDRESS:

INTAKE DATE:

DATE OF BIRTH:
PHONE:

HOME:

WORK:

IDENTIFYING INFORMATION AND REFERRAL STATEMENT

1. Include description of clients (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 clients 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 clients daily
living or became manifest to those around him.

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(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.) and
severity of stressors (see DSM IV, Axis IV).
(c) Note the clients 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 clients 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 wont help me much less himself).

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CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:

Include (1) pertinent dynamic factors in the development of the presenting
complaint, taking into account psychological aspects of the clients life (e.g., family;
employment, etc.), (2) appraisal of insight and motivation for treatment, and (3)
level of functioning or impairment, including the clients 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 clients
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

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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).