Intake Interview Form Analysis Assignment





Intake Interview Form Analysis Assignment

Knowing how to analyze an intake form is essential in social work. The intake form provides the information social workers will use to determine possible identified problems. This assignment will help you learn this concept.

Read the intake form and then use it to answer the prompts below:


Name of Client: Martin McNowhere

Age:    35    DOB:      7-4-1982           Date:  __________________


Marital Status: (circle)   Single    Married    Separated    Divorced


Address: 89 E. Idunno Drive Apt 1100 NYC, NY 56789

Phone: (928)555-2222

Work Status: (Circle all that apply)

  1. Currently employed as An assistant Principal
  2. Looking for employment as ______University professor____________________________________
  3. Involved with local government agency to find employment
  4. Going to college at NYU_______________________
  5. Obtaining vocational training at_________________________________

Any formal diagnoses:    None.

Any medications (dose and frequency):   None_______________

Specific concerns: (Provide reasons for today’s visit. Please be specific about work life, school, and family influences):

I’m here because I’ve been having trouble sleeping. I drink a lot of energy drinks to help me work all day and then take night classes at NYU. I find it hard to focus at work and on my homework reading assignments. Because of my lack of focus, I’ve been scoring low on a few assignments. This causes me a lot of anxiety because I need to graduate soon. I have many financial aid loans out.  I’m not used to dealing with failure. I grew up in a poor family that stressed success in school, sports, and career. I’m the oldest of three and feel obligated to succeed. Both our parents are now college professors after struggling through racism and poverty all their lives. Their success motivates me. The stress from work and school made me lash out at my boss, the principal at the school where I work. I felt badly about what happened. I haven’t been very social lately. I stay home most weekends doing homework. My boss told me to make an appointment here. I’d like help in time management skills, coping with stress and anxiety, and focus.

Any Family History of Mental Illness: Not myself, but my mother suffered from depression, but she’s on meds now.

Possible Services Desired: (Circle all that apply)

Diagnostic Evaluation Development of personal goals
Individual or Family Therapy Sensitivity Training
Development of a Problem Assessment Plan Anger Management Classes
Social services Social skills (group or individual)
Medication review/Prescriptions Legal assistance



After reading the above intake form, use the information to answer the following prompts:

Explain the presenting problem and other possible identified problems of the client. (40-50 words)
Identify any cultural personal biases that might arise during the interview. (40-50 words)
What are the primary concerns of the client? (40-50 words)
Describe any personal or family coping capacities, skills, values, motivations of the client. (40-50 words)
List some of the strengths and weaknesses of the client: (30-40 words)
Identify systems in this client’s life that shape his life circumstances: (40-50 words)
As the social worker assigned this client, how would you use this information to build a rapport with the client? (40-50 words)
Explain whether there are any social phenomena (behavior that influences or is influenced by the client)  in this case (30-40 words):
List some possible measurable client goals you would suggest to the client: