Address *
City *
State *
Zip Code *
E-mail *
Phone *
May we contact you via text? Select One Yes No
Relationship Status Select One Single Married Separated Engaged Divorced Widowed
Number of Children Select One 0 1 2 3 4 5 6 7 8 9 10
Children's Names and Ages
Primary Care Physician
Medical Conditions
Occupation
Employer
Emergency Contact Information
How did you discover Wellness and Relationship Counseling?
How long has this problem occurred?
Briefly describe previous treatment for this issue. Who did you see before and for how long?
Please list any medications you are currently taking and for what purpose as it relates to these issues
Who is the prescribing doctor?
Are you currently receiving individual counseling? Select One Yes No
If yes, please list provider and reason for being in individual counseling
Have you received individual counseling in the past? Select One Yes No
If yes, please list provider and reason for being in individual counseling?
Do you have a personal history of suicide attempt/ideation? Select One Yes No
If yes, please list dates and briefly describe history
Do you have a personal history of mental health hospitalization? Select One Yes No
Do you have a personal history with abuse/addictions? Select One Yes No
If yes, please briefly describe your personal history with abuse/addictions
Have you received previous OUTPATIENT treatment for this issue? Select One Yes No
If yes, please list dates, facility and outcomes
Have you received previous INPATIENT treatment for this issue? Select One Yes No
Are you currently active? Select One Yes No
Date of last use
Do you have a personal history of sexual trauma? Select One Yes No
If yes, to the best of your ability please list dates/ages and briefly describe history
Have you received previous counseling for this issue? Select One Yes No
If yes, please list dates, providers and outcomes
Do you have personal history of family violence - verbal abuse or physical abuse? Select One Yes No
If yes, to the best of your ability please list dates/ages and briefly describe history
Have you received previous counseling for this issue? Select One Yes No
If yes, please list dates, providers and outcomes
Have you had a history of affair in your relationship? Select One Yes No
Name of partner who had an affair
When did affair occur and for how long?
Has affair been disclosed? Select One Yes No
Date of disclosure
Is the affair ongoing? Select One Yes No
Have you received previous couples counseling for this issue? Select One Yes No
If yes, please indicate when you received counseling, for how long and the provider
Is their relational history of domestic violence? Select One Yes No
Who engages in violent behaviors? Select One Partner etc
Is domestic violence ongoing? Select One Yes No
Has there been treatment for this issue? Select One Yes No
If yes, please indicate if, when, where you received couples counseling for this issue
Does your partner have a history of addiction/substance abuse? Select One Yes No
Is partner currently using? Select One Yes No
If yes, please indicate addiction/substance(s) and frequency. Please describe impact on relationship functioning.
Please outline therapy goals/relationship goals - in what ways do you hope your life/relationship will be different as a result of therapy?
Additional information you feel is important for your therapist to know
Additional questions you have regarding the counseling process
