Family & Couples Counseling Screening
For Families & Couples
Thank you for your interest in couples or family counseling at Crescent Counseling Center. This form helps our intake team understand who may participate, what support you are seeking, and how to contact you safely. Please answer based on what you know; you do not need to speak for anyone else. Submitting this form does not guarantee an appointment or establish a counseling relationship. This form is not monitored for emergencies. If you are in immediate danger, call 911.
About You and Your Request
Your full name
*
First Name
Last Name
Name you prefer to use
First Name
Last Name
Your age
*
What type of counseling are you requesting?
*
Couples counseling
Family counseling
Not sure
Will you participate in counseling?
*
Yes
No, I am requesting services for someone else
Not sure
If you are requesting services for someone else, what is your relationship to them?
Your phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Your email address
example@example.com
What is the safest way for our intake team to contact you?
*
Phone call
Email
I need another contact arrangement
If another contact arrangement is needed, please explain how we can reach you safely.
Is it safe to leave a voicemail that identifies Crescent Counseling Center?
*
Yes
No
Do not call
Is it safe to send an email that identifies Crescent Counseling Center?
*
Yes
No
Do not email
Are there any contact restrictions or instructions you would like us to follow?
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What Brings You Here?
These questions help our team understand the request. You do not need to identify a diagnosis or decide who the patient should be. Our clinical team will clarify the treatment focus and any identified-patient designation during assessment.
What is the main concern?
*
Relationship or family concerns only
One person’s mental-health concerns affecting the relationship or family
Both relationship/family concerns and individual mental-health concerns
Not sure
Briefly describe what led you to seek counseling.
*
What would you hope to change or receive help with through counseling?
Whose mental-health needs are part of this request?
Not sure
Prefer to discuss privately
People whose mental-health needs are part of this request
Is counseling primarily being requested to support one particular person’s mental-health treatment, with a partner or family members participating?
*
Yes
No
Not sure
Who is that person?
First Name
Last Name
What is that person's age?
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Potential Participants
Please include yourself if you may participate. List everyone currently being considered, even if participation is not yet confirmed. Providing someone’s contact information does not authorize us to contact them.
Participant
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Awareness and Participation
Are all potential participants aware of this request and willing to consider counseling?
*
Yes
No
Not sure
Prefer to discuss privately
Is there anything you would like our intake team to know before discussing participation or contacting anyone?
You may leave this blank and discuss it privately.
Who should our intake team contact first?
*
You may type a name, or use: Use my contact information above.
Would you like to speak with intake privately before anyone else is contacted?
*
Yes
No
Not sure
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Safety and Private Follow-Up
We ask these questions to help plan a safe intake process. Answer only when it is safe to do so. You may choose ‘prefer to discuss privately’ without describing what happened.
Is there any current or past domestic violence, coercion, threats, stalking, or fear involving anyone who may participate?
*
Yes
No
Not sure
Prefer to discuss privately
Would contacting or scheduling any participant create a safety concern for anyone?
*
Yes
No
Not sure
Prefer to discuss privately
Are there additional instructions for contacting you safely and privately?
For example, a safe time to call or words we should avoid in a message. Please do not include details of violence or abuse here.
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Children, Teens, and Guardians
Our intake team will clarify applicable consent requirements before services begin.
Will anyone under 18 participate or be the person whose mental-health needs are part of the request?
*
Yes
No
Not sure
Minor's full name
First Name
Last Name
Minor's age
Parent or legal guardian's full name
First Name
Last Name
Guardian's relationship to the minor
Guardian's phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian's email address
example@example.com
Safest contact method
Phone call
Email
Text message
Through the primary contact for now
Prefer to discuss privately
Is it safe to leave a voicemail identifying Crescent?
Yes
No
Unknown
Is it safe to email identifying Crescent?
Yes
No
Unknown
Are there additional parents or legal guardians whose information our intake team should review?
Yes
No
Not sure
Anything you would like intake to know about these arrangements?
Are there custody arrangements, court orders, protective orders, or questions about who may consent to services that our team should review?
*
Yes
No
Not sure
Prefer to discuss privately
Which person's age or participation needs clarification?
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Additional Information
Is anyone involved in this request currently receiving services at Crescent Counseling Center?
Yes
No
Not sure
Person’s name
Provider’s name
Please list any current mental-health providers relevant to this request.
Is there anything else you would like our intake team to know?
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