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: Please type in text below: To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.