IN-TAKE ASSESSMENT FORM

Section 1: Personal Information

Name

DOB

Age

Gender Identification

Pronouns

Address

City

State

Email

example@example.com

Phone

Marital Status

Preferred Method of Contact

Section 2: Emergency Contact Name:

Name

Relationship

Contact Information

Relationship

Contact Information

Section 3: Personal Mental and Physical Wellness

Primary Concern

Tell LYI about your history with the primary concerns

Tell LYI about a time you had to overcome a concern in the past, what did you do

Secondary Concern

Tell LYI about your history with the secondary concerns:

Tell LYI about a time you had to overcome a concern in the past, what did you do

Anything else you want to share about your physical and mental wellness

Some College

Community College

4 Year College/University

Other

What is your occupation

How many hours per week do you work

How long have you been in your current occupation:

What are some of your strengths

List your areas of opportunities for growth

Your self care strategies

On a scale of 1-5, one meaning poor and five meaning great how would you rate the following:

Current happiness?

What makes you the most happy in your life currently

Current stress level?

What is causing you stress?

Committed to change?

Share your commitment to change "why"

Professional

Section 8: Partnership Expectations

What are your expectations for partnering with LYI and your time together?

What do you wish to accomplish while partnering with LYI?

Section 9: Patterns of Behavior

Answer the following statements: Yes or No

I start things but rarely finish them?

I set goals for the things I wish to accomplish?

I write down the steps and tasks required to accomplish the goals I set?

If I don't accomplish my goals in the allotted time frame, I disregard the goal in its entirety?

I struggle with following through on tasks?

My expectations are often unrealistic?

I get bored easily?

I don't like asking for help?

People doubt me and what I can accomplish?

I like to prove people wrong?

I like to surprise myself in achieving tasks?

I am my own biggest cheerleader/advocate?

I am my own biggest critic?

Section 10: Authoritarian Agreement

Signature

Date