Intake Packet

Today's Date

Date

How did you hear about our program?

Name(First Middle, Last):

DOB: ___/_____/_____Age Bracket: 텅 18 - 25 텅 24 - 40 40 - 60 텅 60

DOB:

SSN:

Preferred Mailing Address:

City___________________ County:___________ State_____ Zip

City

State

Zip

Phone School:_________________________________________ Grade:

Ethnicity (Mark all that Apply):

Black/African American

Native Hawaiian/Pacific Islander

-0-23

White

Other:

Tribal Affiliation:

Religion:

Non Binary

Employer: ____________________________텅 Full Time

Employer:

Part Time

Phone#:__________________ Address:

Phone#:

Address:

City:_____________________State:_____ Zip Code:

City:

State:

Zip Code:

DOB: ___/_____/_____Age Bracket: 텅 18 - 25 텅 24 - 40 40 - 60 텅 60

Age Bracket:

Email:

example@example.com

City___________________ County:___________ State_____ Zip

County:

Phone #

School:_________________________________________ Grade:

School:

Grade:

Ethnicity (Mark all that Apply):

-1-12

Native Hawaiian/Pacific Islander

Hispanic

White

Other:

Tribal Affiliation:

Religion:

Female

Male

Non Binary

Employer:

Full Time

Part Time

Phone#:__________________ Address:

City:_____________________State:_____ Zip Code:

Zip Code:

Marital Status: Legally Married

Marital Status:

Living With Partner

Separated

Name:

DOB:

Is there a court order to pay child support?

Y

N

Income (Check Applicable): 1 Person Hshld텅 0 – 13,450 텅 13,451 – 22,350 2 Person Hshld텅 0 – 15,93015,931 – 25,550 3 Person Hshld텅 0 – 20,09020,091 –28,750 4 Person Hshld텅 0 – 24,25024,251 – 31,900 5 Person Hshld텅 0 – 28,41028,411 – 34,500 6 Person Hshld텅 0 – 32,57032,571 – 37,050 7 Person Hshld텅 0 – 36,73036,731 – 39,600 8 Person Hshld텅 0 – 40,89040,891 – 42,150

22,351 – 35,750 25,551 –40,850 28,751 – 45,950 31,901 - 51,050 34,501– 55,150 37,051 – 59,250 39,601 – 63,350 42,151 – 67,400

Over 35,751 Over 40,851 Over 45,951 Over 51,051 Over 55,151 Over 59,251 Over 63,351 Over 67,401

Provider:

Policy#:

Address:

Phone#:

City:

State:

What do you hope to accomplish through our program?

What do you believe is your family strengthens?

What are your biggest strengths as a couple?

Person 1: Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship.

1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy)

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.

Person 2: Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship.

1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy)

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.

Have you received couples counseling related to any of the above problems? □ Yes □ No

If yes, when: _____________________________ Where: _______________________________ By whom: ______________________ Length of treatment: _____________________ Problems treated:

What was the outcome (check one)? □ Very successful □ Somewhat successful □ Stayed the same

Have either you or your partner been in individual counseling before? □ Yes □ No If so, give a brief summary of concerns that you addressed.

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol?

Have either you or your partner struck, physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened.

Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems? If yes, who? ___Me ___Partner ___Both of us

Person 1: Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic): 1. 2. 3.

Person 2: Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic): 1. 2. 3.

Signature of Person Completing Intake

Intake Packet

Personal Information (Person 2)