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Intake Form
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Name
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# Emergency Contact Information
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Name
First Name
Last Name
Relationship
Phone Number
Area Code
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Phone Last 4
2) Relationship Status
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Current Relationship Status
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Married
Separated
Divorced
Single
How long have you been together?
How long have you been married?
How long have you known each other?
Prior to this marriage, how many times have you been engaged?
Have you ever been married before?
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How many times?
What are your current living arrangements?
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Own home
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Living with someone else
3) Current Household Family
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Do you have children?
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If yes, please provide information below
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Name
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Last Name
Age
Lives at
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Biological
Adopted
Step-child
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Last Name
Age
Lives at
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Biological
Adopted
Step-child
4) Family-of-Origin
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Mother's Age
If deceased, how old were you when she died?
Father's Age
If deceased, how old were you when she died?
Number of Brothers
Their Ages
Number of Sisters
Their Ages
Briefly describe your relationship with your father
Briefly describe your relationship with your mother
Briefly describe your relationship with your siblings
5) Educational and Spiritual Background
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Select a Choice
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GED
HS Diploma
Associate's/Technical Degree
Bachelor's Degree
Post-Graduate Degree
Other
If degree applies please specify major
Were you affiliated with any church/religion growing up?
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Yes
No
What church/religion?
Are you currently affiliated with any church/religion?
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What church/religion?
Describe your religious upbringing
Describe your current relationship with God
What differences/similarities have you discussed concerning religion/spirituality?
6) Medical History
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Do you have any significant health/medical issues?
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No
If yes, what is/are the health issue(s) and are you limited in any way?
Have you ever had any trauma to the head, unconsciousness, or seizures?
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No
If yes, explain
Have you ever been hospitalized for any mental health reasons?
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No
If yes, please explain when, where, for what reason, and what your presenting problem/diagnosis was
Are you taking psychotropic medications?
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If yes, please list the medication, condition, dosage, dates of usage, side effects, and physician:
Do you currently use alcohol or drugs?
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No
Describe the use of drugs and alcohol (type, amount, frequency)
When did you start using drugs or alcohol?
What has your past use of alcohol been like?
7) Counseling History
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Have you attended counseling previously?
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No
If yes, please explain when (specify date), where and with whom, presenting issues at the time, and the diagnosis given
Have you ever attempted suicide?
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If yes, when?
How many times?
Have you recently had thoughts of suicide?
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If yes, how are what did you plan to do?
What were the circumstances at the time?
Has anyone close to you ever attempted suicide?
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If yes, who, how, and when?
Have you ever been physically, emotionally, or sexually abused?
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If yes, briefly explain (who, what, and when)
Do you have people you can turn to for support?
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If yes, who?
Relationship to you
Briefly explain what concerns you would like to address during counseling
What do you hope to achieve or accomplish through counseling?
Please describe what you believe your spouse’s specific goals are for counseling
What concerns do you hope to resolve by the time you finish?
How did you hear about us?
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