Relationship Therapy Intake Form
Malwina Andruczyk, LCSW, SIFI

When your intake form is received, Malwina will contact you to set up a 15 minute phone screening and you will be on your way to your first session.
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Please provide your full name *
Date of birth *
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DD
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YYYY
What gender pronouns do you use? *
Such as they/them/theirs, she/her/hers, he/him/his, or whatever feels most comfortable and true to you
How do describe your racial and ethnic identities?
Email Address *
Phone Number *
Address *
What are some good times to reach you for a follow up call? *
Relationship style (poly, open, non-monogamous, kink dynamics, only if comfortable sharing):
Current partner(s):
Does your relationship(s) bring you happiness and/or fulfillment?
What is your sexual relationship like with your partner(s)?
Is there any area of your sexuality you wish you could explore more?
How would you describe your communication style? Your partner’s communication style?
What brings you to counseling at this time? *
Is there a something specific, such as a particular event? Be as detailed as you can.
What are your goals for counseling? *
What would you like your relationship to look like in a year? Two years? Five years?
Have you seen a mental health professional before? *
If you have been in treatment before, when was your last mental health session?
What do you consider your greatest strength?
Creative projects/practices (art, music, writing, movement etc.):
Spiritual beliefs:
Self care practices:
Are you engaged with any other healers/doctors/guidance?:
If taking prescription medication for mental health--please list here.
Relationship to drugs & alcohol & if you are currently using either: *
Have you ever been hospitalized for a psychiatric issue? If so--when was your last date of hospitalization? *
Describe your current living situation. Do you live alone, with others, with family, etc? *
Please check any of the following you have experienced in the last 6 months. *
Required
Anything else you would like me to know? *
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