Brooke-Randolph, LLC Intake form
Please use this form if you are coming in for couples counseling
Full name
Your answer
Date of birth
Your answer
Partner's name
Your answer
Children's names, ages, etc.
Your answer
Wedding Date
(if married or engaged)
Your answer
Address
Your answer
Phone number
Your answer
Permission to leave a message at this number?
Email
Your answer
Adoption connection
check all that apply
How did you find me?
What would you most like to get out of our work together?
Your answer
Describe any previous individual or couples counseling experience
Your answer
Describe falling in love with your partner. What were the traits they possessed that made you decide to connect with them?
Your answer
What are the strengths of this relationship currently?
Your answer
Things changed when....
Your answer
What do you imagine it is like being married to you?
Your answer
Is there anything else I need to know about you and your relationship that would be important so that I can be the most helpful? (I will not hold secrets from your partner if you are coming in for couples counseling, but I can help you tell them things you might be afraid to tell them)
Your answer
Any questions for the first session?
Your answer
Health History and Habits
Primary Medical Provider/Family Doctor
Your answer
Address for PMP/doctor
Your answer
Phone for PMP/doctor
Your answer
When was your last exam?
Your answer
List any medical diagnoses
Your answer
Surgeries or hospitalizations, including psychiatric hospitalizations
please include dates and hospital name
Your answer
Current medications
include dose, frequency, and prescribing physician
Your answer
Alleriges
Your answer
Average hours of sleep per night
Your answer
Glasses of water per day
Your answer
Nutritional level of your diet
Caffeine per day
include if coffee, soda, tea, tablets, etc
Your answer
Tobacco use
type and frequency
Your answer
Alcoholic drinks per week
Your answer
Exercise
types, intensity, frequency per week
Your answer
History or current illegal drug use
including misuse of prescriptions
Your answer
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