Couples Counseling Intake Form

PERSONAL INFORMATION

YOUR NAME*

First Middle Initial Last

EMAIL ADDRESS*

PHONE*

BIRTHDATE*

AGE*

GENDER/PRONOUNS*

SEXUAL ORIENTATION*

ETHNICITY*

RELIGION

PARTNER NAME*

First Middle Initial Last

Do you have children?*

Yes

If yes, for each child please list name, age & gender:*

Current living situation (Where? How long? Who is in the household?):*

Employment:*

Full/Part-time job

Self-employed

Student

Not working

Occupation:*

Title:

Education (please list highest grade in school completed and any advanced degrees):*

ABOUT THE COUPLE

Why are you seeking couples therapy now? What is the main problem(s) you hope to address?*

When did you first notice the problem(s)? What was going on in your / the couple’s life at that time? What efforts did you make to resolve the problem(s)?*

What typically happens when the couple disagrees? How do conflicts usually end?*

Has a conflict ever become physical?*

Yes

If yes, please briefly explain:*

Do you want (more) children?*

Yes

Don't know/not sure

Does your partner want (more) children?*

Yes

Don't know/not sure

Do you want to get married (if not currently)?*

Yes

Don't know/not sure

Does your partner want to get married (if not currently)?*

Yes

Don't know/not sure

Have you been in couples therapy before?*

Yes

MORE ABOUT YOU

Have you ever had thoughts of suicide or wanting to kill yourself (now or past)?*

Yes

Have you ever attempted suicide?*

Yes

NOTE: If you are actively suicidal, call 911 or otherwise seek immediate emergency assistance.

Are you currently in individual psychotherapy?*

Yes

Are you currently seeing a psychiatrist?*

Yes

Have you ever been diagnosed with a mental disorder? eating disorder?*

Yes

If yes, please list each diagnosis:*

Have you ever been hospitalized because of a mental health issue?*

Yes

Have you ever had an or disordered eating?*

Yes

Have you ever been arrested, convicted of a crime, and/or incarcerated?*

Yes

Do you currently have any serious or chronic, medical condition?*

Yes

If yes, please describe briefly:*

Please list all medications you take currently, dosage, and what you take them for:*

Please briefly describe your present and past use of alcohol and/or recreational drugs (i.e., substance, amount, frequency, problems, treatment/recovery):*

Please briefly list any current or past trauma(s) or other significant life events you have experienced (e.g., victim of crime, childhood abuse, domestic violence, divorce, death of loved one):*

ABOUT YOUR FAMILY OF ORIGIN

For each immediate family member (biological/adopted/step- parents, caretakers, siblings) provide name, and current age (if living) or year of death (if deceased), if you know:*

What it was like growing up in your household?*

JUST TWO MORE QUESTIONS

Do you have any concerns about attending couples therapy?*

Is there anything else you think I should know about you or the couple?*

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
By signing below, I hereby authorize and permit Cynthia M Lackner (the “Health Care Provider”) to film, record and photograph by audio and video my sessions, whether they are online or in-person.

I understand that uses and disclosures already made based upon my original authorization cannot be taken back. Even if this authorization is revoked, I agree that the Health Care Provider is and will be the sole and exclusive owner of all rights, title, and interest in and to the Recordings, including all copyrights and other intellectual property rights therein, in perpetuity throughout the universe.

I understand that my treatment is not conditioned upon my signing this authorization and that I have the right to refuse to sign this authorization without giving any reason. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AUTHORIZATION.

Signature*

Full Name

First Last

Date*

Human

Thank you for filling out the Couples Counseling Intake Form. Please click SUBMIT below and I look forward to getting back to you.