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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