COUPLES HISTORY FORM

COUPLES HISTORY FORM

THE FAMILY GUIDANCE AND THERAPY CENTER
Please complete and submit. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your family by uploading below.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Information
Partner 1 full legal name:

First NameLast Name
Partner 1 name they go by:

First NameLast Name
Partner 1 pronouns:

Other
Partner 1 date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Partner 1 preferred Contact phone #:
Partner 1 email address:
example@example.com
Partner 2 full legal name:

First NameLast Name
Partner 2 name they go by:

First NameLast Name
Partner 2 pronouns:

Other
Partner 2 date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Partner 2 preferred Contact phone #:
Partner 2 email address:
Partner 1 address:
Is partner #2's address the same as partner 1?

No, I need to enter another address
Preferred language(s):
Primary insured individual’s name:
Social Security # (tricare only):
Primary insured individual’s DOB:
How can we help?
Seeking the following Services:
Primary reason(s) for seeking services:

Other mental health concerns (specify): ___
Please answer the following questions to the best of your ability:
1. Goals: What are your goals for coming here? Please be as specific as possible.
2. Opinions: Is there any difference of opinion among over whether problems exist, or what needs to be done? If so, please give us each person's viewpoint of the problems and solutions.
3. Living Arrangements: Who currently lives in your home(s)?
4. Marriage: Please tell us about your marital status. Is this the first marriage for both? If there were prior marriages, are there any children from them? Are you divorced? Remarried? Separated?
5. Important Events and Stressors: Please share about any important milestones in your relationship that you feel the therapist should be aware of. For example, medical concerns, deaths in family, changes in job, breaches in trust, etc.
6. Family History: Tell us any important information about each partner's family that would help us.
7. Medical History: Are either partner taking prescribed medication? If so, please list who, what, and what it is prescribed for. Please note any other medical diagnosis.
8. Counseling/Prior Treatment History: Please share with us any prior about any prior counseling either partner has received (couples, individual, family, group). What worked? What did not work?
9. Any additional information that you believe would assist us in understanding your relationship? Your therapist will conduct a more in depth assessment during your first session, so feel free to list them rather than going in to detail.
Upload records:

Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your family by uploading.
Cancelof
Should be Empty:

COUPLES HISTORY FORM

Your Information

How can we help?

Please answer the following questions to the best of your ability: