Intake Form

Date *

Name *

Date of birth

Gender

Age

Occupation

Address

Home Phone

Work Phone

Cell Phone

Can we leave a message?

Yes

No

Email *

Employed At

# Emergency Contact Information

Name

Relationship

Phone Number

2) Relationship Status - Current Relationship Status

Married

Separated

Divorced

Single

How long have you been together?

How long have you known each other?

How long have you been married?

Prior to this marriage, how many times have you been engaged?

Have you ever been married before?

Yes

No

How many times?

What are your current living arrangements?

Own home

Renting

Living with someone else

3) Current Household Family Do you have children?

Yes

No

If yes, please provide information below

Name

Age

Lives at

Choose One

Biological

Adopted

Step-child

Name

Age

Lives at

Choose One

Biological

Adopted

Step-child

4) Family-of-Origin

Mother's Age

If deceased, how old were you when she died?

Father's Age

If deceased, how old were you when he died?

Number of Brothers

Their Ages

Number of Sisters

Their Ages

Briefly describe your relationship with your father

Briefly describe your relationship with your mother

Briefly describe your relationship with your siblings

5) Educational and Spiritual Background

If degree applies please specify major

Were you affiliated with any church/religion growing up?

Yes

No

What church/religion?

Are you currently affiliated with any church/religion?

Yes

No

What church/religion?

Describe your religious upbringing

Describe your current relationship with God

What differences/similarities have you discussed concerning religion/spirituality?

6) Medical History

Do you have any significant health/medical issues

If yes, what is/are the health issue(s) and are you limited in any way?

Have you ever had any trauma to the head, unconsciousness, or seizures?

If yes, explain

Have you ever been hospitalized for any mental health reasons?

If yes, please explain when, where, for what reason, and what your presenting problem/diagnosis was

If yes, please list the medication, condition, dosage, dates of usage, side effects, and physician:

Do you currently use alcohol or drugs?

Describe the use of drugs and alcohol (type, amount, frequency)

When did you start using drugs or alcohol?

7) Counseling History

Have you attended counseling previously?

If yes, please explain when (specify date), where and with whom, presenting issues at the time, and the diagnosis given

Have you ever attempted suicide?

If yes, when?

How many times?

If yes, how are what did you plan to do?

What were the circumstances at the time?

Has anyone close to you ever attempted suicide?

Have you ever been physically, emotionally, or sexually abused?

If yes, briefly explain (who, what, and when)

Do you have people you can turn to for support?

If yes, who?

Relationship to you

Briefly explain what concerns you would like to address during counseling

What do you hope to achieve or accomplish through counseling?

Please describe what you believe your spouse’s specific goals are for counseling

What concerns do you hope to resolve by the time you finish?

How did you hear about us?

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13925 City Center Dr Ste. 200, Chino Hills, CA

[email protected]

Phone: +1 951-878-1028

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