Outcomes, Assessment Services, & Intervention Supports (OASIS) - Adult Client Intake

Please provide the following information for our records. Leave any questions you prefer not to answer blank.

Identification

First Name

Last Name

Phone

- -

Email

Permanent Address

Street address

City

State

- Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Demographics

Date of Birth

Age

Gender

Preferred Pronouns

Race/Ethnicity:

Sexual Orientation

Education

Are you a student?

Where?

Year

Major

Relationship and living status

Relationship Status

Number of children

Number of children living in the home

What are your living arrangements?

- Select -alone with roommate(s) with spouse/partner with children with family

Are you satisfied with your living arrangements?

YesNo

Counseling status

Referred by

Are you currently receiving counseling or assessment services elsewhere?

YesNo

Have you had previous counseling?

YesNo

Religious status

Do you consider yourself to be religious?

YesNo

If yes, what is your faith?

Do you consider yourself to be spiritual?

YesNo

Employment

Are you currently employed outside the home?

YesNo

What is your occupation?

Family Information

Please include all significant family members

Significant family member 1

Name

Age

Relationship

Do they live with you?

Open/Close for next significant family member

Significant family member 2

Name

Age

Relationship

Do they live with you?

Open/Close for next significant family member

Significant family member 3

Name

Age

Relationship

Do they live with you?

Open/Close for next significant family member

Significant family member 4

Name

Age

Relationship

Do they live with you?

Open/Close for next significant family member

Significant family member 5

Name

Age

Relationship

Do they live with you?

Open/Close for next significant family member

Significant family member 6

Name

Age

Relationship

Do they live with you?

Does your family have a history of any of the following?

1.a. Aggressiveness, defiance, oppositional behavior

YesNo

1.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

2.a. Attention, activity, and impulse control problems

YesNo

2.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

3.a. Learning problems/disability

YesNo

3.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

4.a. Did not graduate from high school

YesNo

4.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

5.a. Intellectual disability (Mental retardation)

YesNo

5.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

6.a. Psychosis or schizophrenia

YesNo

6.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

7.a. Depression or bipolar disorder

YesNo

7.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

8.a. Anxiety disorder that impaired adjustment

YesNo

8.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

9.a. Tics or Tourette’s

YesNo

9.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

10.a. Autism/Asperger’s Disorder

YesNo

10.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

11.a. Alcohol abuse

YesNo

11.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

12.a. Substance abuse

YesNo

12.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

13.a. Antisocial behavior (assaults, thefts, etc.)

YesNo

13.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

14.a. Arrests

YesNo

14.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

15.a. Abuse or neglect

YesNo

15.b. concern was with...

Mother

Father

Siblings

Mother's Parents

Mother's Siblings

Mother's Grandparents

Father's Parents

Father's Siblings

Father's Grandparents

Health

How would you describe your physical health at present?

- Select -Poor Unsatisfactory Satisfactory Good Very Good

Please list any persistent physical symptoms or health concerns (e.g., chronic pain, diabetes, etc.)

Are you having any problems with your sleep habits?

YesNo

If yes, please describe

Are you having difficulty with appetite or eating habits?

YesNo

If yes, check where applicable

Eating less

Eating more

Binging

Restricting

Other

Are you currently taking any prescribed psychiatric mediation (antidepressants or others)?

YesNo

If yes, please list

Do you regularly use alcohol?

YesNo

If yes, how frequently and how much?

In a typical month, how often do you have 4 or more drinks in a 24-hour period?

How often do you engage in recreational drug use?

- Select -Daily Weekly Monthly Rarely Never

Have you ever felt that your substance (alcohol or drug) use was a problem?

YesNo

What substance(s) do you use?

Has anyone ever told you they were concerned about your substance use?

YesNo

Have you had thoughts of suicide recently (past two weeks)?

YesNo

If yes, please describe

Have you had them in the past?

YesNo

If yes, please describe

Have you ever attempted suicide?

YesNo

If yes, please describe

Have you ever had thoughts of harming other people?

YesNo

If yes, please describe

In the last year, have you experienced any significant life changes or stressors?

YesNo

If yes, please explain

Academic History

Are you currently enrolled in school?

YesNo

Where?

Year?

Major

Do you have a history of:

… been retained or repeated a grade in school?

- Select -No Yes Don't Know

Which grade

… received poor or failing grades?

- Select -No Yes Don't Know

… disliked or refused to do homework?

- Select -No Yes Don't Know

… disliked or refused to go to school?

- Select -No Yes Don't Know

… been tested for special education?

- Select -No Yes Don't Know

… received special education services (had an IEP)?

- Select -No Yes Don't Know

… had a Section 504 plan?

- Select -No Yes Don't Know

… been suspended or expelled from school?

- Select -No Yes Don't Know

… been truant or miss an extended amount of instruction?

- Select -No Yes Don't Know

Indicate the number that best describes your behavior over the past 6 months

1. Fails to give close attention to details or makes careless mistakes in schoolwork.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

2. Has difficulty sustaining attention in tasks or play activities.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

3. Does not seem to listen when spoken to directly.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

4. Does not follow through on instructions and fails to finish work.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

5. Has difficulty organizing tasks and activities.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

6. Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

7. Loses things necessary for tasks or activities.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

8. Is easily distracted.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

9. Is forgetful in daily activities.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

10. Fidgets with hands or feet or squirms in seat.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

11. Leaves seat in classroom or in other situations in which remaining seated is expected.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

12. Is “on the go” or acts as if “driven by a motor”.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

13. Interrupts or intrudes on others.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

14. Blurts out answers before questions have been completed.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

15. Has difficulty awaiting turn.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

16. Talks excessively.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

17. Has difficulty playing or engaging in leisure activities quietly.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

18. Runs about or climbs excessively in situations in which it is inappropriate.

None

0 - Never or Rarely

1 - Sometimes

2 - Often

3 - Very Often

Experiences

Have you ever experienced problems with?

Depression

Anxiety

Panic Attacks

Mood Swings

Anger

Abuse (physical/verbal/sexual)

Repetitive behaviors

Racing Thoughts

Repetitive thoughts

Difficulty concentrating or focusing

Confusing thoughts

Please check the statements that apply to you:

I do not have close friends I can talk to about personal issues

I have a good social support system

My relationship with my family is satisfactory

I have difficulty handling stress

I have difficulty expressing my emotions

I often get extremely angry

At times I have acted in a violent manner

I am having academic or work problems

I have suffered a recent loss: death

I have suffered a recent loss: relationship ending

I have suffered a recent loss: other loss

I have current or past health concerns I would like to discuss

I have sexual concerns I would like to discuss

Emergency contact

Please give the name and phone number of an Emergency Contact

Emergency contact name

Emergency contact phone

Do we have your permission to contact this person if we feel it is necessary?

YesNo

Assessment

What are some of your strengths?

What will the assessment process help you find out?

What do you hope comes of your comprehensive assessment?

Please list your goals.

Submit Form

Master’s and doctoral students in our EPSY graduate programs staff Outcomes, Assessment Services, & Intervention Supports (OASIS). To ensure the quality of services you receive, all counselors in training are assigned licensed faculty supervisors with whom to consult concerning the progress of assessment or counseling. Your session may be both audio and video recorded. The purpose of recording is to provide instruction and feedback to students. All recorded materials and written records are restricted to the internal use of the OASIS and their confidentiality will be strictly safeguarded, with exceptions discussed with your counselor in the first session. Recordings are deleted after every semester.