Couple / Family Therapy

Intake Form

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988
911

Client Information

Please answer questions for all people included in session.

First name

Client A

Last name

Client A

Date of birth

Client A

Gender

Client A

First name

Client B

Last name

Client B

Date of birth

Client B

Gender

Client B

Additional members attending

Who is completing this form?

Contact Information

Phone number - CLIENT A

Email address

Phone number - CLIENT B

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Medical History

Have you previously received individual therapy or are currently seeing an individual counselor?

Yes (Current) Yes (Previously) No

If yes, who received individual therapy?

If yes, what was the primary reason for individual therapy?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

Have you or another family member been previously diagnosed with any psychiatric disorders or medical conditions?

Have you or another family member previously experienced suicidal or homicidal thoughts, ideation, or attempt?

Have you previously received couple or family therapy?

Yes No

If yes, when and for how long?

If yes, why?

Is there anything else regarding you or another family members medical history that we should be aware of?

Family History

Other:

How long have you been together?

Is there anything regarding your relationship you would like us to be aware of?

Do you have any children? (Client A)

Yes No

Do you have any children? (Client B)

Yes No

Please list the name, birth date, sex, and relationship of all children and specify whether they live at home with you.

If yes, briefly describe your relationship with your children.

Briefly describe your relationships with your parents (Client A)

Briefly describe your relationships with your parents (Client B)

Do you have any siblings? (Client A)

Yes No

Do you have any siblings? (Client B)

Yes No

Briefly describe your relationship with your siblings.

Is there anything else regarding your family history that we should be aware of?

Personal History

What is your highest level of education?

Client A

What is your highest level of education?

Client B

CLIENT A

CLIENT B

Are you currently employed? Client A

Yes No

Are you currently employed? Client B

Yes No

If yes, what is your current occupation?

Do you use drugs?

Regularly Occasionally No

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Chemical Use History

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

If additional family members attending session, please provide personal and medical history here:

Military Background

Spiritual or Religious Backgrounds

Cultural/Ethnic Backgrounds

Any current or previous legal history?

Child and Adolescent History: Developmental, milestones, transitions, mental health, medical conditions, school, social, etc.

Is there anything else regarding your personal history that we should be aware of?

Reasons for Visit

Describe the reasons you and your partner or family member(s) are seeking therapy

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

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