Family Intake

Family Intake Form

Please ensure that each family member has filled out the form below
Full Name:

First NameLast Name
Preferred Name:
Date of Birth:

MonthDayYear
Date
Today's Date:

MonthDayYear
Date
Administrative Sex:
Gender Identity:
Marital Status:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Can we leave voice messages?

YesNo
Email Adress:
example@example.com
Name of Insurance company:
Insurance Member ID:
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Do we have permission to reach out to your emergency contact if you are unavailable?

YesNo
Your History:
Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services?

YesNo
Please indicate which type of treatment:

InpatientOutpatientBoth
Who did you see?
How long did you see them?
What did you see them for?
Please describe results of treatment:
Briefly describe what brings you in for family counseling at this time?
List of Symptoms:
Please check any of the following that apply:

AgoraphobiaAngerAlcohol or Drug use/abuseAnxietyAppetiteBeing a ParentBowel TroubleChildhood AbuseChildrenCompulsivityConfidenceDepressionDivorceEating ProblemsEducationEnergy Levels(High or Low)Extreme FatigueFearsFetishesFinancesFriendsGuiltHeadachesHealth ProblemsInferiority feelingsInsomniaLonelinessMaking DecisionsMarriageMemoryMy ThoughtsSuicidal ThoughtsSexual ProblemsSiblingsWorkSelf EsteemStressSeparation
Present Relationships:
How would you describe your current relationship with your family of origin? (Check all that apply

StrainedHostileDistantCloseOver-involvedRockyAbusiveDysfunctionalCut offPositiveIndifferentHarmoniousSupportiveAmicableControllingOther
How do you get along with your spouse or partner?
If Applicable
How do you get along with your children?
If Applicable

Who lives in your household?

	Name	Age	Relationship	Quality of Relationship?
1
2
3
4
5
6
7
8

Please list the family member or members who you are having conflict with:
Please describe the conflict:
What are your biggest strengths as a family?

Please list anyone who you would consider a support system for you:

	Name	Relationship	Length of Relationship
1
2
3

Is there anything else that is important to know about and that you have not written about on these forms?
Should be Empty:

Family Intake Form

Emergency Contact

Your History:

List of Symptoms:

Present Relationships: