Family Intake Family Intake Step 1 of 3 33% Name* First Last PhoneEmail* 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.*NameAgeGenderJob 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?NameConditionMedications/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