Couples Intake Form

Couples Information Sheet
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Name

First NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Pronouns
Client's Cell Phone
Format: (000) 000-0000.
Client's Email
example@example.com
Employer/School
Client's Address

Street Address

Apt/Suite

CityState / Province

Postal / Zip Code
May we add you to our mailing list?
Spouse/Partner's Name

First NameLast Name
Spouse/Partner's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Pronouns
Employer/School
Spouse/Partner Address (if living separately)

Street Address

Apt/Suite

CityState / Province

Postal / Zip Code
Spouse/Partner's Cell Phone
Format: (000) 000-0000.
Spouse/Partner's Email
example@example.com
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship
Insurance Information
Insurance Company's Name
ID Number
Group Number
Member's Name

First NameLast Name
Member's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Members's Relationship to Client
EAP Information (If Applicable)
EAP Provider's Name
EAP Authorization No.
No. of Authorized Visits.
Family Information
Childrens' Name and Ages (If Any)
Relationship Status
Date Of Marriage/Committment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Previous Marriage?
Spouse/ Partner's Previous Marriage?
Have you had previous experience with couples counseling
If yes, how long ago?
Please describe the reasons for couples counseling at this time?
What are you and your spouse/partner's goals for couples counseling?
How were you referred to The Genesis Therapy Center
Should be Empty:

Couples Information Sheet

Emergency Contact Information

Insurance Information

EAP Information (If Applicable)

Family Information