Intake Assessment and Report

Intake Assessment and Report


Your final product will consist of an uploaded digital copy of the recorded intake session, a signed informed consent form and a 3 to 5 page biopsychosocial assessment report.

As a Reminder:

Your instructor will assign you to work with a classmate for these practice sessions, and you will each serve as the practice client for the other. You will use zoom to conduct the practice sessions and to record them for submission to the instructor. In the case of an odd number of students in the class, the instructor will assign you to work in a group of three and will give you additional instructions on how to proceed so that each of the three members will get an opportunity to enact the role of a practice client and a practicing counselor.

Important Notes about the Practice Sessions with Classmates:

  • For the Practice Client:

When you are the practice client, you will be expected to be authentic in your discussions with the classmate who is practicing his or her counseling skills, but please be aware that you have the right to choose what you will or will not share with the classmate. For example, when your background information is being gathered for the intake report, you may choose to share or not to share any significant mental health history, trauma, etc., and should only disclose what you feel comfortable to share. Keep in mind that these are not therapy sessions; they are very time-limited and serve as only a practice opportunity for skill development, so you should go into the sessions with real presenting concerns that would give you some benefit in discussing (e.g., the stress of being a graduate student and juggling multiple priorities) but not a topic with a high-intensity level (e.g., a current unresolved high-conflict situation with a significant other or a trauma history). 

  • For the Practice Counselor:

You are expected to complete several written reports that are submitted only to the instructor for review after the practice sessions in this course. The instructor will not share these reports with your classmates, and you are not to share the reports or any specific content with the classmate who serves as your practice client. In some of the reports, you may be asked to develop a preliminary diagnosis for the practice client, depending on the information you have gathered, and this is simply an opportunity for you to practice your diagnostic skills. Because this is only a skills practice, it is not appropriate for you to share the content of the report with your classmates (or anyone else except the instructor).

Preparation Prior to Practice Session:

  • Connect with and confirm practice client availability. Schedule the practice session. As a reminder, this same practice client should be available for multiple sessions that span this course. Reach out to the instructor should you have any challenges scheduling with your partner.
  • Have your informed consent and opening statement ready.
  • Have the intake session documentation ready.
  • Review the Zoom instructions that were emailed to you at the beginning of the course to learn how to set up and record your video session.
  • Prepare to record the practice session, so you can see and hear yourself and review the effectiveness of your interventions.
  • Prepare to take notes during the session. This will help you formulate your summary towards the end of the session.

Part I: Meet the Practice Client and Tape an Intake Assessment:

  • Conduct and record your first meeting with your practice client using your opening statement.
  • The session should range between 30–45 minutes in length.
  • Provide and complete the informed consent form.
  • Turn in the recorded intake session through digital upload on D2L for your instructor’s review, as needed, or your instructor will give you instructions on how to submit your recorded session and your report.

As part of your grade, your instructor will view a 10-minute portion of the tape. You may suggest a timestamp where you would like the instructor to begin the review. Ultimately, any part of your tape may be reviewed.

Part II: Write a Report:

Follow the details below pertaining to the report’s requirements.

Your written report should be 3 to 5 pages long and should follow APA guidelines for writing style, particularly chapters 3 (“Writing Clearly and Concisely”) and 4 (“The Mechanics of Style”). Clear documentation of services is a very important skill that can result in a client’s services being reimbursed or denied and therefore is a client welfare issue. You should have a title page and a header labeled “Intake Your Name.”

Avoid pejorative language, whenever possible. Use the client’s words within quotation marks to add strength to documentation. Attribute information to the person/court order, etc., reporting/stating information. State information in a behaviorally observable manner.

Example: The client demonstrates poor insight, as evidenced by her report that “I do not have a drinking problem,” although her probation orders mandating treatment indicate that she has three past driving-under-the-influence (DUI) charges.

Nonexample: The client denies being an alcoholic.

A. Biopsychosocial Assessment:

Your biopsychosocial assessment should be three to four pages long and should be documented in such a manner that the diagnosis you choose is clearly supported by the evidence in the documentation. This is what quality assurance (QA) representatives from insurance companies look for when auditing a chart.

Mental status information should be reflected throughout the report when relevant to the subject matter being documented:

  • 3 As (Appearance, Attention, and Activity Level)
  • Speech and Language
  • Mood/Affect
  • Cognition (Thought Process and Content)
  • Insight and Judgment
  • Risk of Harm to Self
  • Risk of Harm to Others

Your written assessment should be documented in the following format:

  • Name (Pseudonym) of Client:
  • Presenting Problem:
  • History of Presenting Problem:
  • Behavioral Observations/MSE:
  • Developmental History: Include developmental milestones met/not; major accidents, injuries, and hospitalizations; and other significant developmental histories.
  • Medical History: Include medical illnesses.
  • Mental Health History: Include mental health diagnoses previously given, treatment received, and treatment outcomes; document traumas, losses, victimization, substance abuse, or other behaviors like gambling, sex, shopping, eating, etc., that might be used to regulate emotion; and document hospitalizations, nonsuicidal self-injury, suicide attempts, or violent behavior toward others.
  • Family History: Include family of origin, current family as the client defines it, and sociocultural information that is relevant to treatment. Document the client’s experience of those relationships.
  • Relationship History: Include significant information related to relationships outside of family, such as friendships, dating relationships, work relationships, relationships with coworkers/bosses/teachers, etc.
  • School/Work History: Include successes, challenges, learning disabilities identified, and frequent changes, if any. Include reasons for those changes.
  • Legal History: Ask specifically about open Child Protective Services (CPS) cases or probation/parole/court orders, including divorce/separation decrees. Ask for copies of orders and a release to speak to caseworkers/probation officers, etc., and document that you received them—it is a practice client, so we will assume you actually would get the documents or releases, as necessary.
  • Strengths/Supports: Include hobbies, friendships, current relationships, pets, sports/exercise, spirituality/religion, civic groups, or personal strengths identified during the assessment.
  • Preliminary Diagnosis: Provide a diagnosis from the current Diagnostic and Statistical Manual of Mental Disorders (DSM) with associated codes as it would be documented in a clinical chart. Check to make certain that the diagnosis is supported by the evidence documented in the biopsychosocial assessment.

Case Conceptualization: Develop an initial case conceptualization integrating theory. Identify potential ethical issues that may need to be monitored or addressed and socio-cultural and spiritual issues that may be relevant to the client’s treatment. Determine if there are any potential legal issues you may encounter. Lastly, identify three areas (in bullet point format) that you need further information, research, case consultation and/or supervision in order to be competent to develop a treatment plan (approximately ½ page).

Self-Reflection: Provide a very brief self-reflection after reviewing your tape using the Interpersonal Process Recall method of self-supervision, which you learned about this week. Identify your strengths and challenges. Specifically note any ethical, legal or sociocultural issues that might be a focus for supervision and any transference or counter-transference issues that may be affecting the therapeutic relationship. Lastly, examine multicultural and pluralistic trends, acculturation, and advocacy in relationship to your own attitudes and beliefs related to the counselor’s role (approximately ½ page).

Your final product will consist of your report in a Microsoft Word document (approximately 3–5 pages in length). Your report should be written in APA format in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.

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