FAMILY THERAPY INTAKE FORM

Complete Individually (for clients ages 14+)

First name: ______________________________ Last name: _____________________________

Age: ________ Date of Birth: ___________________ Ethnicity: __________________________
Religion: __________________________________ Marital Status: _______________________
Sex/gender: _________________ Number of children: ____ Ages of children: ______________
Home address: _________________________________________________________________
______________________________________________________________________________
Who do you live with? ___________________________________________________________
Phone: _____________________________________
Email: ________________________________________________________________________
Name of emergency contact: ______________________________________________________
Phone: _____________________________________
EMPLOYMENT INFORMAITON:
 On sick leave, as of this date: ______________ Return to work date: ______________

I was:  Full-time or  Part-time

at: ________________________________________ Position: __________________
 Full-time at: _________________________________ Position: __________________

 Part-time at: _________________________________ Position: __________________

 Not working because: ___________________________________________________

 Student at: ____________________________________________________________
HOW YOU FOUND THIS CLINIC:

 Word of mouth  I’m a former client  Psychology Today

 Google search, using these words: _______________________________________________
 Other: ______________________________________________________________________

50
PSYCHIATRIC AND MEDICAL HISTORY
Please list any psychiatric or problems you have been diagnosed with:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any medical or “physical” problems you have been diagnosed with:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any medications you currently take, dose, and what you take them for:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of family doctor: ______________________________ Phone: ______________________
Date of last check-up/physical: ______________________________
Results:
____________________________________________________________________________
______________________________________________________________________________
Name of Psychiatrist: ________________________________ Phone: ______________________
Date of last visit: ________________________________
Results:
______________________________________________________________________________
______________________________________________________________________________

MENTAL HEALTH TREATMENT HISTORY

Have you ever been hospitalized for psychological or psychiatric reasons? Yes / No
If yes, please describe when and where you were hospitalized, and for what reasons.
______________________________________________________________________________
______________________________________________________________________________

51
Have you ever received family counseling? Yes / No
If yes, for what problems? ________________________________________________________
When: ____________________________ Where: _____________________________________
With whom: ______________________________________ Length of treatment: ___________

Was the outcome successful? □ Very □ Somewhat □ No change □ Got worse

Have you ever been in individual counselling before? Yes / No
If yes, give summarize the concerns addressed: _______________________________________
______________________________________________________________________________
CURRENT HABITS
Please describe your current habits in each of the following areas. Write N/A if it doesn’t apply
to you.

Smoking: ______________________________________________________________________
Gambling: _____________________________________________________________________
Drinking alcohol: ________________________________________________________________
Drug use: ______________________________________________________________________
Caffeine intake: _________________________________________________________________
Exercise: ______________________________________________________________________
Eating problems: ________________________________________________________________
Sleeping: ______________________________________________________________________
Fun and relaxation: ______________________________________________________________

CURRENT STRESSFUL LIFE EVENTS

No Yes If yes, please describe

Economic problems
Difficulty accessing healthcare
Legal issues or crime
Cultural issues
Family conflict or lack of support
Social problems

52
Educational or occupational difficulties
Housing problems
Grief or bereavement
Other

QUESTIONS ABOUT YOUR FAMILY

How close do you feel to your family members? (circle one)
1 2 3 4 5
distant very close

Explain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How well do you get along with your family members?

1 2 3 4 5
poorly very well

Explain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Describe your family’s household rules?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

53
What are your expectations for family counseling?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What are your goals for treatment objectives? (check all that apply):
□ Improve communication □ Conflict resolution □ Parenting skills
□ Problem-solving □ Increase emotional safety □ More physical safety
□ More quality time together □ Resolve individual issues □ More autonomy
□ More respect/understanding □ Power and control issues □ More hobbies
□ Less harsh discipline □ More sharing of the chores □ Help for children's behavior
□ Other (specify):

What have you already tried to address these difficulties?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Whose idea was it to come to therapy? _____________________________________________

Was there a prompting event that led someone to make this call? Why seek help now?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What are your greatest strengths as a family?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Make at least three suggestions you could personally do to improve family relationships.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Does anyone in your family drink alcohol or take drugs to intoxication (get drunk)? Yes / No

54
If yes, who, how often, and what drug/alcohol?
______________________________________________________________________________
______________________________________________________________________________

Has anyone in your family physically restrained, harmed, or injured another family member?
(e.g., pushed, shoved, grabbed, slapped, etc.) Yes / No

If yes, who, how often, and what happened?

______________________________________________________________________________
______________________________________________________________________________

Is your family at risk for splitting up? □ Yes □ No □ Unsure

If yes or unsure, please explain.
______________________________________________________________________________
______________________________________________________________________________
Has anyone in your family withdrawn or given up trying to work things out? Yes / No
If yes, who? ________________________________________________________
Circle your current level of overall stress.
1 2 3 4 5
no stress very stressed

Circle your current level of stress within your family?

1 2 3 4 5
no stress very stressed

Name the top three concerns you have in your family (“1” being the most problematic).
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________

How important is it to you to improve the quality of your family relationships?

1 2 3 4 5
not important extremely important

55
How willing are you to make “working on these relationships” a priority in your life?
1 2 3 4 5
not willing extremely willing

Is there anything else you would like to mention related to the above statements?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Finally, draw a graph indicating your level of family satisfaction from the start until now. Note
any important events in your life (e.g., birth of a child, death of a family member, etc.).

Complete satisfaction (100)

No satisfaction (0)

Family Timeline
At the beginning Now

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

56