Intake Form Template Page 2
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4Present Marriage (or significant relationship)
Years known each other ____ Years married ____ Date married __________________
Children of this marriage (names/ages)
Stepchildren (names/ages)
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Have you been married before? ____
If one or more prior marriage(s), please list below (use back of page if more space is needed):
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Family of Origin (Parents & Siblings)
Father’s name __________________________________________________
Age _____
Occupation ____________________________
Present state of health ____________________________________________
If deceased, year/cause ___________________________________________
Parents still together ______ Divorced ________ Remarried __________
Mother’s name __________________________________________________
Age _____
Occupation ____________________________
Present state of health ____________________________________________
If deceased, year/cause ___________________________________________
Brothers & Sisters
Age
Marital Status
Occupation
Location
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Parent category: Medical