Couples Intake FormFill out this form before your first appointment Name * First Name Last Name Name First Name Last Name Email * Phone (###) ### #### Marital Status Single Married or Common-Law Emergency Contact Name/Phone number/Relationship More about you Tell me why you both would like to start counselling * What do consider to be your strengths as a couple and separately? Please list your 3 greatest accomplishments as a couple and individually? What are some challenges that you think limit you or are obstacles to you moving forward in counselling? Prior Treatment Have either of you previously seen a counsellor or any other type of mental health provider? Yes No If yes, when and for how long? What was the focus of your treatment? Were you able to resolve your concerns? Are either of you currently taking any psychiatric medication? Yes No If so, please list Are either of you taking any other medications or supplements? Have you ever experienced any of the following? * Suicidal thoughts Homicidal thoughts Panic attacks Grief or depression for an extended period of time Mania Hallucinations or delusions Alcohol and/or substance abuse Any other addictive behaviours If you answered yes to any of the above, please tell me more What significant events or life changes have you experienced in the past two years? Please identify if there is a family history of any of the following ADHD Alcohol/Substance Abuse Bipolar Depression Domestic Violence Eating Disorders Obesity OCD Schizophrenia Suicide or suicide attempts Anxiety Please describe how you both are sleeping? Are you both getting around 7-9 hours of sleep? Please describe how you both have been eating? Please describe your sex life. How often are you having sex? Are you both happy with the amount and way you are intimate? How much time do you spend as a couple each week? Please tell me anything else I need to know Thank you! I will get back to you shortly to book an appointment
