Family Therapy Intake Form Family Therapy Intake Form User Code (Kindly do not use your name. Your User code has been sent to your email) * How old are you? * * Date of Birth Gender * Address * Are you currently? * A studentEmployedSelf-employedRetiredUnemployed What is your marital status? * SingleMarriedDivorcedPartneredWidowedOther Who are you in the family? * FatherMotherOffspringOther Family Relation If an offspring, what position are you? (Write N/A if this doesn’t apply to you) * Name the top three concerns that you have in your family (“1” being the most problematic) * What have you already tried to address these concerns? * What are your biggest strengths as a family? * What are your expectations for counselling? * How important is it to you to improve the quality of your family relationships? * Not ImportantSlightly ImportantModerately ImportantVery ImportantExtremely Important How willing are you to make “working on these relationships” a priority in your life? Not WillingSlightly WillingModerately WillingVery WillingExtremely Willing Are you managing/ or managed in the past any psychological health concerns * YesNo If yes, kindly provide more information of the psychological health concerns Are you managing/ or managed in the past any physical health concerns * Yes If yes, kindly provide more information of the physical health concerns Are you experiencing any stressful life event(s)? * YesNo If yes, kindly provide more information of the stressful event(s) * I certify that the information provided on this form is true to the best of my knowledge * I acknowledge the use of the information provided on this form for therapy sessions * I acknowledge that I have read and understand the informed consent (request a copy from the admin if you don’t already have one) If you are human, leave this field blank. Submit Δ
