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Revised Intake form w/ multi-choice items for SI, drinking, drug use



  • Angela DeGiaimo, LCSW

    The files you linked is actually your consent to release information form.

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  • Laura Forsyth

    Hi Angela, 

    Thanks for catching the slip! And, had already revised the initial revision, with an item tracking referral sources in greater detail.

    Let's try again - link to SP Intake Ques Rev2 (google drive)

    BTW, all my stuff is a total work in progress, and this intake questionnaire is no exception. Am already wondering it's too long or missing something important. Time and use will tell... Feedback and any suggestions greatly appreciated!

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  • Jill Cain

    Thanks so much for sharing! Gave me some ideas!

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  • Permanently deleted user

    I have just read through the form.  Generally, I like it!  I would add the following:

    To the question about "are the concerns described above making things difficult for you...  I would add "home" and  "Community". (your work, in the community, at school and/or at home"


    To the question about level of education.  I would add "Also include any vocational training you may have had.


    To the question of "if you are currently a student", I would add "what college, university or vocational school do you attend"


    to the question "If you work" I would add "if you work or volunteer at an agency or business, what kind of work do you do?"


    I would enrich the harm to others section and include the following questions:

    Have you ever attacked someone with serious intent to harm?

    Do you experience voices in your mind that instruct you to act violently?

    Do you tend to have conflicts with other people?

    Maybe not in that order, but we need to also assess for harm to others much like we assess for harm to self.

    That's my feedback.  Thanks for a great form.

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