couples counselling Intake Form

couples counselling Intake Form

J G Gillis Counselling: Judy G Gillis, MC, CT, CCC
Name of One member of couple

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of Other member of Couple

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Primary Care Physician

First NameLast Name
Current Therapist / Counsellor

First NameLast Name
Therapist's Phone Number
Please list the problem(s) which you are seeking help?
Current Issues

CommunicationTrustInfidelityMental Health Issues - partner 1Financial disagreementsMental Health Issues - partner 2Increased sex driveChange in appetiteParenting differencesIncreased irritabilityDecreased sex driveOther
Are you currently living together?

YesNo
Do you entertain thoughts of separating / leaving the other person?

YesNo
How often do you have these thoughts? If above answer is "No", please indicate n/a.
On a scale of 1 to 10, (ten being strongest) how strong is your desire to save your relationship currently?

1

2

3

4

5

6

7

8

9

10

1 is Weak, 10 is Strong
Current relationship complaints - partner 1
Current relationship complaints - partner 2
Psychiatric History:
Outpatient treatment

YesNo
If yes, Please describe when, for whom, and nature of treatment
Psychiatric Hospitalization

YesNo
If yes, Please describe when, for whom, and nature of treatment
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

	Have you ever taken it?	Dates	Dosage	Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

Other medications?
Family Psychiatric History
Has anyone in your family been diagnosed with or treated for:

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcohol abuseOther
Who was diagnosed, and how did that illness affect family relationships?
Check if either of you has ever tried the following

MethamphetamineCocaineStimulants (pills)HeroinLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasyOther
Family Background and Childhood History:
Were you adopted?

YesNo
Where did you grow up?
Did your parents divorce?

YesNo
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe for partners 1 and 2 when, where and by whom.
Personal History
Are you currently:

WorkingStudentUnemployedDisabledRetired
Are you currently:

MarriedPartneredDivorced
Do you have any children?

YesNo
Have you ever been arrested?

YesNo
How did you hear of my services?
Emergency Contact

First NameLast Name
Phone Number
CONFIDENTIALITY AGREEMENT

We understand that therapy can be difficult and bring forward upsetting topics. We are willing to undertake therapy because we are both committed to the process of building a stronger relationship.

We understand that anything we say in session is confidential, and we agree not to disclose another person's life details to an outside party.

We also understand that our counselling therapist will not divulge anything we reveal to her to a third party, unless:

- either of us is a danger to ourselves and/or others;
- there is a child or vulnerable person at risk;
- we reveal instances of sanctuary trauma: where a member of the medical profession has abused power and assaulted either one of us; AND/OR
- the court subpoenas our therapist's records or testimony.

We agree that we will abide by the cancellation policy of our therapist: notification at least 24 hours in advance of any missed appointment, or we will be charged half-rate for the missed appointment.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

couples counselling Intake Form

Psychiatric History:

Past Psychiatric Medications

Family Psychiatric History

Family Background and Childhood History:

Personal History