Intake Information Form - Couples printable pdf download

Judith Smithchild

Today’s Date: ________________________

M.Ed., LPCC-S, LICDC-S, NCC

Intake Information Form—Couples

Instructions: To assist us in helping you, please fill out this form as fully and openly as possible. All private information is held in

strictest confidence within legal limits. If certain questions do not apply to you, leave them blank.

Demographics

1) Name: ______________________________________

2) Age: ________

3) DOB: _______________

4) Gender: __M ___F __Transgender __in Trans.

Sexual identity: __Hetero. __ Gay __Lesbian __ Bi-sexual

5) Home Address: __________________________________________________________________________

Street & Number

City

State

Zip

6) Weight: _________ 7) Height: _____87) Eye color: _________ 9) Hair color: ______________ 10) Race: __________

11) Ethnicity _____________ 12) Years of education: ______ If currently a student: College: _______________________

Year: _________ Major ____________________________________________ Expected graduation date: ______________

13) Occupation: ______________________________ 14) Employer: ____________________________________________

How long ?: ____________

Problems ?: ___ yes ___ no Position: _____________________________________________

Responsibilities: _______________________________________________________________________________________

Communication with you:

14) Cell ____________________________ Home Phone:_____________________ Business _____________________

E-mail address __________________________________________________________________

May we email/text you information? ____yes ____no

15) Emergency Contact Person Name: __________________________________ Phone number: ______________________

16) Are their children ? No: ____ Yes _____ Children’s names and ages:

____________________________________________________________________________________________________

17) Are children or partner currently involved in counseling? Yes _____ No ______ With whom: ______________________

Counseling History

18) How did you hear about this office, or who referred you?: __________________________________________________

19) Are you receiving counseling services at present?: No__ Yes __ Briefly describe: ________________________________

Have you had counseling in the past?: No ___ Yes___ Provider : __________________________ Years of Service:_____

Issues addressed: ________________________________________ Past diagnosis: _____________________________

Medical History:

20) List current medications:

______________________________________________________________________________________________________________________________

Physician’s name: ____________________________ Physician’s address: _________________________________________

21) List any major illnesses (ie. Diabetes, fibromyalgia, cancer, heart disease)and/or operations you have had or any current

illness:

_____________________________________________________________________________________________________

Intake Information Form - Couples