Intake information in the box

Registration No: Address:

Name

Age:

Gender:

Educational qualification:

Occupation:

Income:

Marital status:

Whether client stays with parents:

Whether client stays with spouse:

Whether have any siblings, if so how many:

What is the position of the client in the family: Eldest, middle or youngest or only child:

Anyone in the family having conflicts:

Anyone in the family is suffering/has suffered from any physical disorders:

Presenting problem: (This should be recorded as the client narrates) Date of onset of the problem:

Precipitating factor if any:

Duration of problem:

Any counseling taken:

How intense is the problem and how does it affect the client?

 has to take leave from work place / school/ college

 Cannot carry on even the routine work

 Does not want to do anything

Interview with family members/spouse/the concerned person

 Their view point in regard to all of the above

 The interview with family members should cover all aspects that are covered in the interview with
the client. In addition the following need to be covered.

Relationship: Patient’s relationship with family members:

 If unmarried:

 With Mother,Father, Brothers, Sisters:

Any other relative staying with patient

 With friends: How many friends does the patient have? How does the patient relate to them?

 With neighbours

 With school and class mates

 With the teachers in school

 With other authority figures

 With playmates

 In the games field

Educational history:

 In School/College:

 How is the client in studies and academic performance?

 Does the client come up to the expectations of parents and teachers?

 How has the performance been over the years?

 Do they find that there is sudden deterioration in studies and academic performance?
  Have they received any complaints from the school authorities regarding the client’s
performance?

 Since when have they noted that the client is not the same in regard to academics as he or she
used to be?

 Had they done anything about it so far? If so what?

 After their efforts had there been any improvement?

 When did they decide to consult a counselor?

Work history:

 What occupation is the client involved?

 How regular is the client for work?

 Has the client been complaining about work place? If so what?

 Generally how has the client been fairing in work?

 What is their perception about client’s relationship in the workplace? With Boss:

With colleagues:

With subordinates:
  Whether the client is accompanied by someone (This helps to determine if the client has social
support)

The above few observations can provide important information about the client that may not otherwise
be revealed through interviewing or one-to-one conversation.

Step 2: When client enters the office, pay close attention to the following:

 Note the personal grooming

 Note things as obvious as hygiene

 Note things such as whether the client is dressed appropriately according to the season

 Note if client is talking to himself or herself in the waiting area

 Note if the client is pacing up and down outside the office door

 Record all observations

These types of observations are important and may offer insight into the client’s illness.

Step 3: Establish rapport

The next step for the psychologist is to establish adequate rapport with the client by introducing himself
or herself. Speak directly to the client during this introduction, pay attention to whether the client is
maintaining eye contact. Mental notes such as these may aid in guiding the interview later. Note if clients
appear uneasy as they enter the office, then immediately attempt to ease the situation by offering small
talk or even a cup of water. Many people feel more at ease if they can have something in their hands.
This reflects an image of genuine concern to clients and may make the interview process much more
relaxing for them. A complete MSE is more comprehensive and evaluates the following ten areas of
functioning:
1) Appearance. The psychologist notes the person’s age, sex, and overall appearance.
These features are significant because poor personal hygiene or grooming may reflect
a loss of interest in self care or physical inability to bathe or dress oneself.

2) Movement and behavior. The psychologist observes the person’s gait (manner of
walking), posture, coordination, eye contact, facial expressions, and similar
behaviors. Problems with walking or coordination may reflect a disorder of the
central nervous system.

3) Affect. Affect refers to a person’s outwardly observable emotional reactions. It may

include either a lack of emotional response to an event or an overreaction.

4) Mood. Mood refers to the underlying emotional “atmosphere” or tone of the person’s
answers. Whether the person is in a sad mood, happy mood, angry mood etc.

5) Speech. The psychologist evaluates the following:

a) the volume of the person’s voice

b) the rate or speed of speech

 c) the length of answers to questions
d) the appropriateness of the .answers
e) clarity of the answers and similar characteristics
6) Thought content. The examiner assesses what the client is saying for indications of
the following which are indicative of certain typical disorders. Each of the following
will have to be checked by the learner/ trainee.

All the cases should be written verbatim in a narrative style. What questions were asked by the
psychologist and what answer was given by the client. At the time of answering the questions how was
the client answering? (For instance was the client hesitating? Was the client free in communicating? Was
the client evading any question? Was the client focusing on the interview? What was the general
demeanour of the client while answering in the interview session? Was the client in a hurry to finish the
interview and go off? Was the client showing unwillingness to continue with the interview?

An example of how to write the interview session is given below:

Client’s name:

Interview No: Date:

Session No: Time:

Purpose of the Interview:

The client was referred to me for taking a detailed case history. Start of the session:

The client Ms. Y came in. I greeted her and asked her to please come in and take her seat. She was
accompanied by her husband. I offered him also a seat. However as the interview started I asked Ms.Y if
it would be all right we both talked alone and her husband waited for a while outside. (It is always
important that we meet the client alone first and hear her version before interviewing those who
accompany. The reason is that such a behaviour on the part of the psychologist makes the client feel
good and contributes to establishing rapport quickly.)

The client’s appearance: The client was well dressed, neat and clean. She looked bright but somewhat
anxious.

I decided to make sure that the client is comfortable and told her that she can make herself at home
here and whatever she would tell me will be kept completely confidential. Only that information, which
she says can be passed on to other family members, would be done so. I am a psychologist working here
and she can feel free to convey whatever she wants.

Then Ms.Y started to tell me about the problems she is facing with her husband. He does not seem to
understand her and suspects her if she goes out. She said that she is also working and in her work she
has to interact with a lot of men and her husband does not like it and most of the time fights with her. In
the last few months the ‘husband has started doubting her integrity.
The problem as told by Ms. Y should be written down verbatim and clearly.

.......................................................................

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Next question:

The client’s reply (along with the leaner’s observations):

How did the interview session end?

As the time allotted to the client is generally one hour, I ended the interview in the following manner.

Ms. Y, I think today we have discussed your problem particularly from the relationship and your
experience angles. It has been possible to understand when your problems started, what precipitated it
and how you have been handling the same. Your efforts are really appreciated. However there are many
things we need to discuss with each other. For instance, the difficulty you are facing in your relationship
with your husband and the effect of all this on your family life, work life etc. Do you think I have
understood your problems correctly? Would you like to come for another session sometimes next week
as is convenient to you? Can we fix up next Saturday 10 a.m. for the next session? May be we will like to
give some psychological tests which may help us and you to understand your problem better. The client
responded that she would like to come next week at the time specified. I called the husband for a while
and told him that I would like to see him next time when Ms Y comes for the session. We both stood up,
and shook hands and the client and her husband took leave.

My observation: When the client left I found that she was looking slightly more relaxed and was happy
that she was listened to and her problem could be put across by her clearly to the counselor.

Plan of action: Continue the interview and gather more information about the dynamics underlying the
various conflicts that she has expressed. A session with the husband is required to understand the
problem from his angle too.

Today’s session was able to achieve the purpose with which it started.

Important: Everything being said by the client and by the learner should be recorded verbatim as