Cns 736 Assignment 2

Assignment 2.
For this assignment, I chose to use the intake form from Dr. Robin Lowey & Associates
Psychological Services. I chose this form because it was readily available on the internet and had
a very different format from the one at my internship site. I was unable to use the intake
assessment from my internship site because it is housed in our medical software and consists of
multiple pages across eight tabs. After review, I found the following factors:
Effective:
1. This intake form asks the client about their current habits (sleep, eating habits, exercise, and
alcohol/drug use). It allows them to circle all that applies. Asking specifically about these habits
(as they may be symptoms of mental illness) is more effective than just asking generally about
their hobbies or day-to-day life.
2.The intake form asks if the client has had any major life changes in the past year. This question
is particularly useful because it gives the counselor a broad background and may allow the
counselor to locate how events are impacting the client (even if the client doesn’t realize it or
think it’s impacting them).
3. The form includes a section about occupational information, but it doesn’t just include “where
do you work?” and “how long have you worked there?” The section asks about work-related
stressors and if the client is happy at their place of employment/in the current position.
4. The form clarifies that email communication may not be confidential.
5. The form asks if the site has permission to leave a message at each of the listed phone
numbers – which ensures they are considering confidentiality.
6. The form has a section that asks the client to circle any symptoms they are currently
experiencing. The listed symptoms are common signs of potential mental illness (like suicidal
ideation, eating difficulties, etc) which allows the counselor to quickly establish a baseline.
7. There is a comprehensive section asking about family history of psychiatric and mental health
conditions.
8. The form asks about the state of their physical health and any persistent medical issues the
client is facing which demonstrates they’re considering the whole person.
9. The form asks what the client’s goals are and where they see themselves needed growth,
which is a very important foundation for a therapeutic relationship.
10. This is very specific, but the question that asks about recreational drug use does so in a very
neutral and non-judgmental way which encourages client honesty.
Ineffective:
1. I find that the section asking about a client’s current family status (the questions about how
many kids they have and the ages of their kids) don’t allow for much information gathering.
Perhaps this was just the demographic I worked with at my internship site, but our intake form
asked about DSS involvement, who the kids live with/what custody arrangements might be, if
any concerns about the children that are impacting them, etc.
2. The form asks about the client’s relationship status, length of their relationship, and quality of
relationship on a scale from 1-10. It might be more beneficial to ask safety questions, such as “do
you feel safe in the relationship?” or “have you ever felt threatened by your partner?” than just
about the quality of the relationship on a numbered scale.
3. I don’t find that the form offers enough options for a client to describe their gender. Especially
if a client is coming in for body dysmorphia, issues around gender identity, etc, having the
options of only male, female, and transgender might be isolating or negatively impactful.
4. There are two separate questions for medications – one question that asks the client to list
psychiatric medications and one that asks the client to list medications for medical issues. I think
this could be confusing for the client. It might be more beneficial to simply have a list of
bulletpoints where a client can give the medication name and put what they’re taking it for
beside it.
5. The short questionnaire about depression and suicidal ideation is not very specific. Instead of
asking “have you had any suicidal thoughts recently?,” it might be more helpful to ask things
like “Have you ever wished you could just go to sleep and not wake up?” or “Have you ever
thought things might be better without you here?” People may not always realize that some
thoughts are suicidal.
6. Besides the notation that emails might not be confidential, there is no other discussion of
confidentiality on the form or any other mention of relevant ethics (like the client has the right to
revoke consent at any time).
7. There is no section asking the client about any recent or current homicidal ideation. Such a
section should be added.
8. The acknowledgement the client must sign ends with the line “Further, I understand it cannot
be guaranteed that I will feel better after completion of treatment.” I feel the acknowledgement
section should have been longer and more detailed, stating that all efforts with be made to
accommodate the client and help them reach their goals, etc. Ending with that line feels like the
list of side effects at the end of a medication commercial. While a similar sentiment should be
stated somewhere, it should be a more balanced statement.
9. There are only a few short questions about alcohol and drug use and no section to help
determine if the client has any issues regarding these. There are no questions about potential
withdrawal symptoms, if the client wants help with use issues, etc.
10. The form overall lacks sections where the client could provide explanations or any additional
information. The blanks are very short and are usually only a single line long. The form could
use some additions for writing space.

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