Couples Intake Form

GENERAL
Name (required): Date of birth
Address:
City: State: ZIP:
Home phone: May I leave a message? YesNo
Work/Cell phone: May I leave a message? YesNo
Email: May I contact you via email? YesNo
Employer/school:
Occupation:
Emergency contact: Phone: Relationship:
Educational background:
Learning disabilities:
Religious upbringing:
Present affiliation/identification (if any):
Current living situation:
Reason for seeking counseling/therapy at this time:
What do you hope to achieve with therapy?

Previous counseling (dates/names of therapists):

MEDICAL HISTORY
General health:
Are you now under a physician’s care? YesNo
If yes, reason for care:
Physician’s name: Telephone:
Medications:
Reason for medication:
Have you ever been hospitalized for a mental illness? YesNo
Describe:

Have you ever considered or attempted suicide? YesNo
If yes, please explain:

Have you ever been in a drug, alcohol or other treatment program? YesNo
If yes, please provide details:

Do you currently drink alcohol? YesNo
How much/how often:
Do you currently use recreational drugs? YesNo
How much/how often:
Do you feel you have a problem with alcohol or drugs? YesNo

FAMILY INFORMATION

Significant partner status (please select):
SingleEngagedMarriedDivorcedSeparatedLiving togetherRemarriedWidowed
Name of significant partner:
If living together, how long?
If married, how long?
If previously married/partnered, please indicate:
Name of former partner Years together
Reason no longer together
Children from current relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age
Children from previous relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age

Parents and step-parents (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
Siblings and step-siblings (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Issues I would be interested in addressing in couples counseling:
Other comments:

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