Background Information
Feeling stuck for what kind of information you should gather in your first session in order to meet your intake goals?
Consider the below:
- Current Problem – what is the major concern that led you to seek help (assessment/intervention)?
- Additional impacts that may not have been listed in referral/consent form
- When the problem started and how it may have changed over time; how are these issues impacting on your daily life?
- Risk assessment (if applicable)
- History:
- Family - living situation
- Development – birth, milestones
- Accidents, trauma, illness
- Client’s medical history, including current medications
- Psychiatric history – personal and family
- History of any previous treatments; has the client seen a psychologist before?
- Educational and/or occupational status
- Strengths
- Relationships – important relationships, including intimate relationships.
- Substance use
- Are there any legal matters relating to the presentation?
- Goals:
- Goals may vary across multiple clients (i.e. couples, teenagers, children and parents)
- What does the client hope to achieve?
- Discuss frequency of sessions (e.g., weekly, fortnightly, monthly) and encourage to book in advance
Note: This process looks different for each clinician. The importance is gathering the right information that allows you to consider development, context, system, and client (these factors all interact with the presenting problem). Depending on the client, this may be gathered over more than one session.
