Family/Couple Intake
Note: This form should be completed for every individual participating in family or couples counseling. If you are seeking counseling as an individual fill out the Individual (Adult). If you are bringing in your child for individual counseling services, please complete the Child/Adolescent Client Intake Form. Please Note, all collected information is confidential and for our center's use only. The information will not be released to anyone outside of our counseling center without your written permission.
Are you interested in Family or Couples counseling? *
Your email and phone number: *
Your answer
Adult Client 1 Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Your answer
Street Address: *
Your answer
Are you currently taking in medication? Please write name. (or write N/A) *
Your answer
Have you ever seen a Psychiatrist or any other mental health provider? If yes, when? (or write N/A) *
Your answer
Have you been having any thoughts of harming yourself or others? *
Your answer
In an emergency, contact (write name, phone number, relationship) *
Your answer
Adult Client 2 (write name, DOB, sex) *
Your answer
Your email and phone number: *
Your answer
Are you currently taking in medication? Please write name. (or write N/A) *
Your answer
Have you ever seen a Psychiatrist or any other mental health provider? If yes, when? (or write N/A) *
Your answer
Have you been having any thoughts of harming yourself or others? *
Your answer
For Families: Client 3 (write name, DOB, sex) If not family, write N/A *
Your answer
Are you currently taking in medication? Please write name. (or N/A) *
Your answer
Have you ever seen a Psychiatrist or any other mental health provider? If yes, when? (or N/A) *
Your answer
Have you been having any thoughts of harming yourself or others? (or N/A) *
Your answer
For Families: Client 4 (write name, DOB, sex) If not family, write N/A *
Your answer
Are you currently taking in medication? Please write name. (or N/A) *
Your answer
Have you ever seen a Psychiatrist or any other mental health provider? If yes, when? (or N/A) *
Your answer
Have you been having any thoughts of harming yourself or others? (or N/A) *
Your answer
For families: If there are more people who will join in family counseling, please add all here (write name, DOB, sex for each) or N/A. *
Your answer
Are they currently taking in medication? Please write name for all who are taking medications and name of medication. (or N/A) *
Your answer
Have they ever seen a Psychiatrist or any other mental health provider? If yes, when? Please write all names and providers next to each. (or N/A) *
Your answer
Have they been having any thoughts of harming themselves or others? Please write all names and specify. (or N/A) *
Your answer
Does everyone above live at the same address? Write yes or no. If not, please explain. *
Your answer
For the adult(s), which best describes you? (choose all that apply) *
Required
Do you have any other children not listed above? If so please provide names, ages, and with whom they live. Or write N/A. *
Your answer
List any other individuals living in your home other than children. Or write N/A. *
Your answer
What are the issues for which you are seeking counseling? Please be as specific as possible. (These could be your individual or collective concerns) Or write "premarital." *
Your answer
What have you previously tried in order to resolve these issues (e.g. pastoral counseling, talking with family/friends)? Has anything been helpful? *
Your answer
Is there any family history of mental illness or substance abuse? If so, please list which client, relationship, and diagnosis: *
Your answer
Has a family member or close friend ever committed suicide? *
Your answer
Goals are very important in counseling. They provide us with a focus and direction that will help us to help you. Please list the goal(s) that you and your family hope to address and achieve in counseling. Please be as specific as possible. *
Your answer
How did you learn about our office? (Please check one and provide name as indicated): *
Required
Do you have a specific Cumberland counselor you'd prefer to work with? Please write their name or write N/A. *
Your answer
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