You are the Intake Coordinator for a mental health center


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You are the Intake Coordinator for a mental health center. Your role is to gather patient information using a questionnaire. This data collection aims to provide a more holistic understanding of the patient’s human development to the medical team for proper diagnosis and treatment.

The Board of Directors has requested a report that explains why each question on the questionnaire is being asked. They want to ensure that the questions encompass all aspects of a patient’s background. Your job is to review the questionnaire and write a report that explains why each question is being asked and how the information gathered from each question is helpful for the medical team.

  • What is your age? Were you born premature or with any health conditions?
  • What was your birth weight? What is your current height and weight?
  • What is your ethnic background?
  • Which city and which neighborhood did you grow up in?
  • How many schools have you attended and why?
  • Who lived in the home with you where you were raised?
  • What is your parent’s education level?
  • How would you classify your relationship with your parents?
    • Great/Healthy
    • Neutral
    • Not Good/Unhealthy/Dysfunctional
  • What was the income range of the person/people who raised you?
    • $0-$20,000/year
    • $20,000-40,000/year
    • $40,000-60,000/year
    • $60,000-80,000/year
    • More than $80,000/year
  • Have you ever been abused (sexually, physically, or emotionally)?
  • What challenges have you had to overcome in your life? How do you think these challenges have impacted you?
  • What physical disabilities do you have?
  • What mental health conditions have you been diagnosed with or feel you may have?
  • What grades did you earn in grades K-12?
  • Which extracurricular activities did you participate in?
  • What is your highest level of education?
  • List each job you have had and how long you worked there.
  • What religion were you raised in? What is your religion now?
  • Which of the following illnesses or diseases run in your family:
    • Diabetes
    • Heart Disease
    • High Blood Pressure
    • High Cholesterol
    • Mental Illness (depression, anxiety, eating disorders, bipolar, ADHD, schizophrenia, addiction and substance abuse, PTSD, insomnia, other)
    • Cancer
  • How often do you socialize with friends each month?
  • Describe your diet and exercise throughout your life:
    • Birth to age 18
      • Healthy (range of fruits, vegetables, protein, dairy, and carbohydrates)
      • Neutral (some fruits, vegetables, protein, dairy, and carbohydrates, but some junk food and fast food)
      • Unhealthy (too many calories or not enough calories, low levels of fruit, vegetables, protein, dairy, carbohydrates, high levels of junk food and fast food)
  • How would you describe your personality? (i.e. optimistic/pessimistic, angry/happy, easy-going/high strung, etc.)
  • Were you exposed to asbestos, lead paint, second-hand smoke, or poor water quality growing up?
  • Did you go to annual medical, dental, and vision appointments growing up? When were your last appointments for these?
  • Have you experienced or witnessed domestic violence?
  • How many and which languages were spoken in your home growing up?
  • Did your parents read to you as a child? What was your access to books and toys?
  • Did your parents drink alcohol or use drugs while you were growing up?
  • Did your mother drink or use drugs while pregnant with you?
  • Were you ever neglected or abandoned?

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