Intake Form


Print off this page and bring to your first session for child concerns for 12 years old and under:

Click here for a Biographical Information Form – Children in PDF format. Click here for a Biographical Information Form – Children in Word format.


Please fill out this form for each partner prior to your first couple counseling session. If you prefer to fill out paper forms, click here for a PDF version or MS Word version. You need to print these, fill them out and print a copy for each partner for your first couple counseling session

FAMILY/DEVELOPMENT INFORMATION

Information regarding Parents:
Information regarding Children:
Answering options for “Whose Child *” section below:

B Both of ours, natural child MA My child, adopted (or taken on)
BA Both of ours, adopted (or taken on) S Spouse’s natural child
M My natural child SA Spouse’s child, adopted (or taken on)
Information regarding Significant Others (Brothers, Sisters, Grandparents, Step-relatives, Half-relative):

SOCIAL INFORMATION

SPIRITUAL/RELIGIOUS INFORMATION

LEGAL INFORMATION

EDUCATION INFORMATION

EMPLOYMENT/VOCATIONAL INFORMATION

PHYSICAL HEALTH INFORMATION

Any recent changes in:

COUNSELING/PRIOR TREATMENT INFORMATION