Couples Initial Paperwork

Emergency Assistance

If this is an emergency, call:

Crisis Line: (503) 988-4888
911

Client Information

First name

Last name

Date of birth

Identified Gender / Pronouns

Marital or Relationship Status

Email address

Phone number

Mailing Address and Physical Address:

Background

With which cultures/races/ethnicities/languages do you identify?

Any others you live with or any extended family roles you take on in your household?

What are your reasons for visiting a counselor? What kind of symptoms are your experiencing, if any?

What do you think might be causing the above - include all speculations regardless.

Things that make you most nervous about counselors/counseling:

Your top three things, outside of your relationship, that get you stressed on a day-to-day basis or generally in your present life:

Have you been treated by a doctor in the last 12 months?

Yes No

Date of your last physical exam

How is your health in general? Do you have any somatic complaints? Share your sleeping habits/patterns.

Rate yourself in your relationship, using the following prompts/thoughts/concepts:

If married or cohabitating, has either of you threatened to separate/divorce or move out as a result of the current relationship problems? (If you are not living together please answer N/A).

Have either you or your partner struck, physically restrained, injured or used violence in relation to the other person?

Do either you or your partner feel like they are the recipient of emotional or psychological stress? (This can feel like coercion, manipulation or gaslighting.)

Past hospitalizations/Previous treatment

Have you ever been hospitalized or had thoughts around suicide? When was the last time for either?

Any attempts? Other forms of self harm? When/how many/details..?

Trauma

Please share any exposure to instances of abuse/neglect/natural disasters, etc.

Are there any significant people in your life that have passed that are important for me to know about?

Subtances Used/Frequency/History

Are you, or your partner, now taking, or have you taken any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants)? If yes, please give details (dates, types, amounts, addictions, treatment, and present use).

Are you, or your partner, now taking, or have you taken within the past two years, any prescribed medication? If yes, please give details (dates, types, dosage, and present use).

Employment

Write about your educational history/successes/obstacles:

What is your work history? What types of jobs have you held? What is the level of satisfaction in your current position?

How have social class and economics impacted your development and present situation?

Have you served in the military? If so, please provide details of your service:

Multicultural

How might my race/gender/ethnicity impact our counseling relationship? How can we address this so you feel comfortable?

Pick three words that best describe your family of origin. They can be anything (related to race, politics, emotion, etc.)

Write briefly about your experience with religion and spirituality and how you see them connected, or unrelated, to counseling.

Do you have any disabilities or unique learning styles you’d like me to know about?

How does your sex life, gender, or sexuality and impact your life?

Technology

What do you use technology for (phone, gaming, porn, etc.)?

How much time do you spend per week online or in front of a technology device?

What's your connection/relationship with social media?

Miscellaneous

How do you unwind or what do you do for recreation?

Similarly, what coping skills (positive or negative) do you use for stressful situations?

How willing are you to complete homework? (select one):

Very willing

Willing

Neither willing nor unwilling

Unwilling

Very unwilling

How (mentally) healthy do you feel right now? (select one):

Very healthy

Healthy

Neither healthy nor unhealthy

Unhealthy

Very unhealthy

How can we measure therapy is working for you and what are your goals?

Emergency Contact Information

In case of emergency, whom shall I contact, and what is their relationship to you? What's the best way for me to reach them?

Your information will be encrypted.

Christopher G. Marquardt, LPC

cgm counseling

I have been practicing for over 5 years, specializing in existential and mindfulness therapy. I have a direct style that provides a safe and compassionate environment conducive to introspective conversation and a growth mindset. cgm counseling welcomes clients (adolescents and couples) of all backgrounds.

971 270 0792, christopher@cgmcounseling.com
cgmcounseling.com
2304 East Burnside Street, Suite 105, Portland, Oregon, 97214