Family Individuals Intake Form

Family Individuals Intake Form

Each Member Fill out Individually (for clients ages 14+)
Name *
DOB *
Sex/Gender *
Ethnicity
Religion
Email address
example@example.com
Please describe any current significant or stressful life events you have been experiencing:
How close you feel to your family members? (1 = distant, 5 = close) *

1 2 3 4 5
How well do you get along with your family members? (1 = poorly, 5 = great) *

1 2 3 4 5
Rate your current level of stress overall: (1 = no stress, 5 = extreme stress) *

1 2 3 4 5
Rate your current level of stress in the family: (1 = no stress, 5 = extreme stress) *

1 2 3 4 5
How important is it to you to improve the quality of your family relationships? (1 = not important, 10 = extremely important) *

1 2 3 4 5 6 7 8 9 10
How willing are you to make working on these relationships a priority in your life? (1 = not willing, 10 = extremely willing) *

1 2 3 4 5 6 7 8 9 10
Name the top three concerns that you have in your family:
1. *
2. *
3. *
What are the family and/or household rules? *
What are your expectations for therapy? *
What would you like your family to work on (please check all that apply) *

Improve communication Conflict resolution Parenting skills Problem solving More emotional safety More physical safety More quality time together Resolve individual issues More autonomy More respect / understanding Power and control issues More hobbies Less harsh discipline More sharing of the chores Help for child's behavior Other (specify):
What have you already tried to address these difficulties? *
Whose idea was it to come to therapy? *
Was there a prompting event that led someone to make this call? (Why seek help now?) *
Has anyone in your family physically restrained, harmed, or injured the other person? *

Yes No
If yes, who, how often, and what happened?
How would you describe the communication style in your family? *
Do you perceive that anyone in your family has withdrawn or given up on trying to work on things? *

Yes No
If yes, who?
What are your biggest strengths as a family? *
What are at least three things you could personally do to improve relationships in the family regardless of what your family members do? *
Is there anything else you would like me to know?
Should be Empty: