Relationship Intake Form Relationship Intake Form To be completed by the client without influence. Please complete the information on this form. These are some of the questions we might ask you during your first session in order to help you achieve your goals better. Completing this form accurately helps reduce the time spent on these questions during your session, so we can focus on other areas. It may seem long, but most of the questions require only a check, so it will go quickly. If you have any questions, please send us a WhatsApp message on 08096642604 and we would respond ASAP. SECTION 1: PERSONAL INFORMATION User Code (Please do not include your name). * How old are you? * Date of Birth Address * Gender * Height (feets) Weight (Kg) Referred By (Leave blank if you were not referred by anybody) Emergency Contact (Name) * Emergency Contact (Number) * Emergency Contact (Email) Relationship With Emergency Contact * SECTION 2: WHY ARE YOU SEEKING HELP? Reason One * Please write in details to enable us to have an idea of how to help you efficiently Reason Two Please write in details to enable us to have an idea of how to help you efficiently History (Please include details of when your relationship setbacks started. Provide details such as when, how and dates) * So far, what solutions (even if brief) have been helpful in resolving the reason you are booking this session? * If part of a couple (e.g. married, single but in a relationship, cohabiting, etc.), how long have you been together? (Put N/A if this doesn't apply) * If coming as an individual, when have you last been in a relationship and for how long? (Put N/A if this doesn't apply) * Is there/has there been any physical violence in your relationship? If yes, state when, if none, put N/A * State any major events impacting on your relationship that have recently happened or are coming up * Improvement Goals (What would you like us to focus on during sessions) * How would you classify your eating habit? * Poor Good Excellent How would you classify your sleep? * Excellent Good Poor Please state any previous counselling experience: (Reason/when/for how long) SECTION 3: SUICIDE AND HOMICIDAL RISK ASSESSMENT Have you ever had feelings or thoughts that you didn't want to live? * No Yes Maybe Do you currently feel that you don't want to live? Maybe No Yes Has anything happened recently to make you feel this way? Would anything make it better? Please specify Have you ever tried to kill or harm yourself in the past? * Yes No Have you ever had the thought to kill or harm someone else? * Yes No SECTION 6: YOUR EXERCISE LEVEL Do you exercise regularly? * Yes No How many days a week do you get exercise? How much time each day do you exercise? SECTION 7: SUBSTANCE USE Have you ever been treated for alcohol, drug use? * Yes No If yes, for which substances? Please provide dates Check if you have ever tried any the following (check all that applies) Tobacco (Cigarettes, pipes, cigar, or chewing) Methamphetamine Cocaine LSD or Hallucinogens Ecstasy Methadone Tranquilizer/sleeping pills Stimulants (pills) Marijuana Alcohol Heroin Pain killers (not as prescribed) How many caffeinated beverages do you drink a day? Have people annoyed you by criticizing your drinking or drug use? Maybe Yes No Have you ever felt you ought to cut down on your drinking or drug use? Yes No Maybe Have you ever felt bad or guilty about your drinking or drug use? Yes No Maybe SECTION 8: FAMILY BACKGROUND AND CHILDHOOD HISTORY How much time did you spend with your immediate family when growing up? * Very much Not so much Averagely How many siblings do you have and what is your position in the family? * Did your parents' divorce or seperate? * No Yes If yes, how old were you when they divorced or separated? If your parents divorced or separated, who did you live with while growing up? Describe your mother and your relationship with her * Describe your father and your relationship with him * Describe your relationship with your siblings * Has anyone in your immediate family died? * No Yes If yes, please state who and when SECTION 9: TRAUMA HISTORY Do you have ANY traumatic experiences? * Yes No If yes, please provide details (please include details if there are multiple traumatic experiences) SECTION 10: EDUCATION HISTORY What is your highest educational level or degree attained? * How would you grade your overall performance? * Above Average Below Average Average How would you grade your performance in primary school? * Above Average Average Below Average How would you grade your performance in secondary school? * Above Average Average Below Average Did you date much in school? * Were you bullied at any time in school? * Yes No If yes, please provide details of the bullying experience Did you bully anyone at any time in school? * Yes No If yes, please provide details of the bullying experience SECTION 11: OCCUPATIONAL HISTORY Are you currently * Working Unemployed Retired A student Unable to work Self-employed How long in present position? * What is/was your occupation? SECTION 12: RELATIONSHIP HISTORY AND CURRENT FAMILY Are you currently * Widowed Divorced Other Married Single Partnered How long? * Are you sexually active currently? * Describe your relationship with your spouse or significant other, if currently in a relationship (if none, write none) * Do you have children? * Yes No If yes, please list their ages Describe your relationship with your child/ children (if any) SECTION 13: LEGAL/ FINANCIAL Do you have any pending legal problems? * No Yes Do you have any pending debt problems? * No Yes SECTION 15: SPIRITUAL LIFE Do you belong to a particular religion or spiritual group? * Yes No Do you find your involvement helpful during this trying period, or does the involvement make things more difficult or stressful for you? Very much helpful Helpful Unhelpful Very much unhelpful Is there anything else that you would like us to know? (if none, write none) Where did you hear about us? * Family and FriendsGoogle SearchInstagramFacebookYouTubeLinkedInReferral from a Professional (e.g. Doctor, Counsellor, Pastor, etc.)Other * 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 my 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
