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Do you perceive that anyone in your family has withdrawn or given up on trying to work on things?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?
Submit
Should be Empty: