Family Intake

Step 1 of 3

Name*
First Last
Phone
Email*

How can we help your family?
Briefly describe the primary concern about your family.*
Briefly describe the development of this issue from onset to the present.*
What are your goals for family counseling?*
Has anyone in your family been in counseling before?*
- Yes
- No
If yes, why was counseling sought and what was the outcome?

Tell us about your family.

Please list the family members living in the home.*

Name	Age	Gender	Job or Grade

How do family members express anger in your home?
How is love & affection expressed in your family?
What are the strengths of your family?
What are areas of struggle for your family?

Has anyone in your family been diagnosed with a physical or mental illness?

Name	Condition	Medications/Treatments

Is there anything else you would like us to be aware of?

*If you have not Read and Electronically Signed the Informed Consent Documents, please do so now. Sign Form

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