HN205 Unit 4 Applied Skills for Human Services
1
Kaplan University School of Arts and Sciences
HN205 Applied Skills for Human Services
COURSE #
Intake Form
[With instructions for completing each field]
Client: [Insert the client’s name] Date: [Insert the date of the interview]
Presenting Problem:
[Document the problem as the client understands it and as the client communicates the issues. The
client may present more than one problem, issue, or concern. All of them should be documented.
You should document both the problem as the client presents it as well as any professional
understanding of the problem.]
How Client Presented in the Interview:
[Describe the client’s emotional state, behavior, and attitude, and include any non-verbal
communication such as dress, hygiene, tone, mannerisms that the client presented in the initial
interview.]
Client’s Expressed Goals, Expectations, Requested Services:
[Document what that client is seeking, any goals mentioned, and his or her expectations of the
service.]
Additional Relevant Information:
[Provide any information that will be helpful to understanding the client and the situation. This can
include information about family members, previous counseling experiences, coping mechanisms, or
any other pertinent information.]
Impressions and Recommendations:
[Give a brief overview of your assessment of the client and his or her issues, problems, and
concerns. Add any recommendation that you think will be appropriate to pursue in counseling such
as a goal, task, or referral.]
Human Services Professional Signature: [Sign your name]
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