Medical Intake Form Page 3
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1
2
3Relationship status:
N/A (Child)
Single
Married
Widow
Divorced
In a significant relationship
Separated from partner ____________ Date
__________
!
If you are in a relationship,
please complete:
Partner's Name:
How long in
relationship: ______
Name(s)
Please list all people with
whom you currently live with.
!
!
!
Name(s)
Age(s)
Relationship to person
Please list parents, brothers
receiving services
and sisters who are not
currently living in your home.
Yes
No
Age(s)
Relationship to person
Are you adopted?
receiving services
Please describe any family
information (current/past)
that might be helpful:
Mental health issues
•
Medical issues
•
Deaths in family
•
Divorces, step-parents
•
Any type of abuse/trauma
Are you currently
Yes
No
If Yes, what religion?
•
religiously affiliated?
Former religious affiliation?
Yes
No
If Yes, what religion?
! !
! !
!
___________________________________________________
_______________________________________
Signature of Person Completing Form and Relationship to client
Date
! 3
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