Youth Intake Interview Form PDF Details

Navigating the complexities of youth support services begins with understanding the individual needs of a young person, and this is where the Youth Intake Interview Form plays a crucial role. Designed meticulously to gather comprehensive information, the form includes sections on personal details, family background, education, living situation, hobbies, peer relationships, medical history, and mental health. Starting with basic details like name, birth date, and contact information, it progresses to more intricate questions related to school performance, family dynamics, and personal interests. The form aims to paint a detailed picture of the youth's life, touching on sensitive topics such as mental health issues, experiences of abuse, and any criminal history within the family. This thorough assessment allows professionals to tailor their approach, ensuring that the support provided aligns with the individual's specific circumstances and challenges. By delving into various aspects of the youth's life, from their academic goals and home rules to their health and social circles, the form serves as a foundational tool in planning effective interventions and support mechanisms.

QuestionAnswer
Form NameYouth Intake Interview Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesintake form clinical summary example, clinical psychology intake interview template, interview intake form, intake interview

Form Preview Example

Youth Intake Interview Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Today’s Date:

Youth’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle

 

 

 

 

Last

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male/Female:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (

 

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Social Security #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Co:

 

 

 

 

 

 

 

 

 

 

Mother’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s Name

 

 

 

 

 

 

 

 

 

DOB:

 

 

Occupation:

 

 

 

 

 

 

 

 

 

 

 

DOB:

Occupation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (H)

 

 

 

 

 

 

(W)

 

 

 

 

 

 

 

 

 

 

 

 

Phone (H)

 

 

(W)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Persons Present for Assessment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self identified race/ethnicity/cultural heritage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language youth/family speak at home (if not English)

 

 

 

 

 

 

 

 

 

EDUCATIONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Building:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Grade:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credits:

 

 

 

GPA:

 

 

 

 

IEP?

 

 

 

No

 

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

Ever been diagnosed with ADHD?

 

No

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

Attendance Pattern:

 

Regular

Skips

 

 

 

 

Tardies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What are your Academic Goals?: GED

 

Diploma Trade School College

Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you participate in any school sports?

Are you in any clubs or other school activities?

What do you like best about school?

What do you like least about school?

Page 1

What is your favorite class/subject?

Have you ever been suspended?

 

 

No

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever been expelled?

 

 

No

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have a history of fighting in school? No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there a teacher, counselor, coach, or other adult at school that you can talk to? No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Guidance Counselor:

Do the parents help/support youth in school? No Yes:

How did youth do in school in the past? (elementary, middle school, grades, fighting, suspensions):

Additional Notes:

FAMILY STRUCTURE/LIVING SITUATION

Individual Lives with:

 

 

 

 

 

Father

 

Stepfather

 

Legal Adoption

 

Mother

 

Stepmother

 

Relatives:

 

 

Both (biological)

 

Other:

 

 

 

 

 

 

 

 

Who else lives in the home? (siblings, relatives, significant others, etc.)

Home Environment:

Describe the relationships and communication within the home (conflicts, how people get along):

What are your rules at home?

Page 2

What consequences do you typically face when you don’t follow the rules?

What consequences did you face at home for this referral?

What are some things you do together as a family?

Significant family events, traumas, or major changes/Dates:

What are some strengths you have as a family?

What adult do you spend most of your time with? (Looking for a positive adult role model)

Name:Relationship:

Which extended family members provide support and how?

Name:Relationship:

History of running away: No

 

Yes: (How often, most recent occurrence)

 

 

 

 

 

 

Any previous out of home placements?:

Family Criminal History:

 

 

Mother:

 

No

 

Yes, Crime(s):

 

 

 

 

 

 

Father:

 

No

 

Yes, Crime(s):

 

 

 

 

 

 

Siblings:

 

No

 

Yes, Crime(s):

 

 

 

 

 

 

Relatives:

 

No

 

Yes, Crime(s):

 

 

 

 

 

 

Additional Notes:

YOUTH

What do you like to do for fun? (favorite hobbies/interests)

What are some things that you’re good at?

Page 3

What are some things your child is good at?

How would you describe yourself?

Do you go to any youth groups, church groups, or clubs?

Have you ever had a job?

Are there positive people in your life who serve as a resource/mentor for you?

Name:Relationship:

Name:Relationship:

Additional Notes:

PEERS

How would you describe your friends?

 

Lots of Friends

 

Few Friends

 

No Friends

 

Mostly Older

 

Mostly Younger

 

Same Age

Do parents know and approve of friends? No

 

Yes, Comments:

 

 

 

 

 

 

 

 

 

Have your friends changed over time? How/Why?

Have any of your friends gotten into trouble with the law? No

 

Yes:

 

 

 

 

 

How do your friends do in school? (grades, attendance, behavior)

What do you value in a friend?

MEDICAL

Does youth, or has youth ever, taken medication?

 

No

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any pregnancy, delivery, or developmental milestone (walking, talking, potty training) concerns?

Page 4

Is there any history of head injury? No

 

Yes:

 

 

 

 

 

Any past hospitalizations, serious injuries, or frequent or chronic illnesses?

MENTAL HEALTH

Have you ever received any psychological or counseling services? No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever attempted suicide? No

 

 

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had suicidal thoughts or gestures?

 

No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any history of depression or withdrawal?

 

No

 

 

Yes:

 

 

 

Any history of sleeping or eating problems?

 

 

 

No

 

 

 

Yes:

 

 

Any auditory or visual hallucinations?

 

No

 

 

 

Yes:

 

 

Family History of Mental Illness:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother:

 

No

 

Yes, Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

Father:

 

No

 

Yes, Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

Siblings:

 

No

 

Yes, Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

Relatives:

 

No

 

Yes, Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

Have any family members been in counseling or treatment for mental illness or substance abuse?

Additional Notes:

Victimization/Abuse:

 

 

 

 

 

 

 

Physical Abuse?

 

 

 

No

 

 

 

Yes:

 

Emotional Abuse? No

 

 

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

Sexual Abuse?

 

 

No

 

Yes:

 

Page 5

DRUG AND ALCOHOL

History: (date/age of first use, date/age of last use, heaviest use, frequency, tolerance, method of ingestion, etc.)

Alcohol No Yes:

Marijuana No Yes:

Mushrooms No Yes:

Acid No Yes:

Methamphetamine No Yes:

Cocaine No Yes:

Pills No Yes:

Heroine No Yes:

Inhalants (huffing)

 

No

 

Yes:

Cigarettes No Yes:

Other:

Drug of choice:

Have you ever been under the influence of drugs or alcohol while at school? No

Yes

 

 

 

 

 

 

 

 

 

Have you ever (unsuccessfully) attempted to quit using drugs or alcohol before? No

 

 

Yes:

 

 

 

 

 

 

 

 

 

Has anything bad ever happened to you because of your drug or alcohol use? (school, home, legal,

friends, work) No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever done a “wake and bake”? No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 6

Have you ever combined drugs in order to enhance an effect? (stacking) No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever used one drug to counteract the effects of another drug? (morphing)

 

No

 

 

Yes

Have you ever been in drug and alcohol treatment or received an assessment?

 

No

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family Substance Abuse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother:

 

No

 

Yes, Substance(s):

 

 

 

 

 

 

 

 

 

 

Father:

 

No

 

Yes, Substance(s):

 

 

 

 

 

 

 

 

 

 

Siblings:

 

No

 

Yes, Substance(s):

 

 

 

 

 

 

 

 

 

 

Relatives:

 

No

 

Yes, Substance(s):

 

 

 

 

 

 

 

 

 

 

Additional Notes:

SAFETY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are any weapons available in the home, or does youth have access to weapons? No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does youth have preoccupation with or use of weapons? No

 

Yes:

 

 

 

Any history of fire setting?

 

No

 

Yes:

 

 

 

 

 

 

 

 

 

 

 

Any history of animal abuse?

 

 

No

 

 

Yes:

 

 

 

 

 

 

 

 

 

Any concerns about anger management or impulsivity?

REPAIRING HARM

Who was hurt by your actions?

What have you already done to make up for your actions?

Is there anything else you could do?

What can you do to show people you will make better choices in the future?

GOALS

What are some of your short-term goals? (within the next month)

What are some of your long-term goals? (within the next year)

Page 7

What are some goals you would like to work on with me?

How can I help you achieve these goals?

Additional Notes:

Page 8

SHORT TERM COMPETENCY DEVELOPMENT/SKILL BUILDING AREAS

PLANNING/GOALS

1.POSITIVE ADULT: Is there a positive adult to support the youth with meeting the goals? If not, GOAL:

2.HEALTHY IDENTITY: Is the youth involved in any positive activities or pursue any positive interests? If not, GOAL:

3.COMMUNITY CONNECTIONS: Is the youth engaged with any educational/vocational activities or involved in any community groups or resources? If not, GOAL:

4.REPAIRING HARM: Has the youth taken responsibility for his/her actions; do he/she understand the impact of his/her behavior; has he/she made efforts to repair harm? If not, GOAL:

Page 9

How to Edit Youth Intake Interview Form Online for Free

You'll be able to prepare clinical intake interview form effectively with our PDFinity® PDF editor. Our editor is continually developing to give the very best user experience possible, and that's thanks to our dedication to constant enhancement and listening closely to customer feedback. Starting is easy! All you need to do is adhere to the following basic steps down below:

Step 1: Hit the orange "Get Form" button above. It's going to open up our tool so that you can start filling in your form.

Step 2: This editor grants the opportunity to modify PDF forms in various ways. Change it with any text, correct what's already in the document, and add a signature - all readily available!

As a way to finalize this PDF document, make sure you type in the necessary details in each area:

1. Fill out the clinical intake interview form with a selection of essential blanks. Gather all the important information and make certain absolutely nothing is overlooked!

clinical psychology intake interview template writing process explained (step 1)

2. Just after this section is filled out, go to type in the relevant details in all these: Persons Present for Assessment, Self identified, Language youthfamily speak at home, EDUCATIONAL INFORMATION School, Credits, GPA, IEP No Yes, Ever been diagnosed with ADHD No, Attendance Pattern Regular Skips, Grade, What are your Academic Goals GED, Do you participate in any school, Are you in any clubs or other, and What do you like best about school.

Part number 2 of filling out clinical psychology intake interview template

3. Completing What is your favorite classsubject, Have you ever been suspended No Yes, Have you ever been expelled No Yes, Do you have a history of fighting, Is there a teacher counselor coach, Guidance Counselor, Do the parents helpsupport youth, How did youth do in school in the, and Additional Notes FAMILY is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

clinical psychology intake interview template conclusion process detailed (stage 3)

People frequently get some points wrong when completing Additional Notes FAMILY in this part. Ensure you read twice whatever you enter here.

4. Filling out Additional Notes FAMILY, Relatives Other, Legal Adoption, Stepfather Stepmother, Who else lives in the home, Home Environment, Describe the relationships and, and What are your rules at home is paramount in the fourth form section - you should definitely devote some time and fill out each blank!

How one can complete clinical psychology intake interview template stage 4

5. The pdf must be completed with this particular area. Further you'll see a detailed list of blank fields that need accurate information for your form usage to be complete: What consequences do you typically, What consequences did you face at, What are some things you do, Significant family events traumas, What are some strengths you have, What adult do you spend most of, Relationship, Name, Which extended family members, Relationship, Name, History of running away No Yes How, and Any previous out of home placements.

Filling in section 5 of clinical psychology intake interview template

Step 3: Right after you've looked once more at the details in the file's blank fields, just click "Done" to conclude your form. Make a 7-day free trial subscription with us and gain direct access to clinical intake interview form - download or edit from your personal account. FormsPal is dedicated to the privacy of our users; we make sure all personal data going through our system continues to be protected.

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